Treating Heart Failure and Atrial Fibrillation

Is the end of Digoxin nearing?

Written by John Steuter, MD

Digitalis has been used for over 200 years to treat patients with heart failure and atrial fibrillation (afib). Digoxin is used for rate control of afib and in the treatment of heart failure, yet has recently come into question with concern for increased mortality.

Digoxin’s Role

Digoxin’s mechanism of action involves inhibiting the Na-K-ATPase pump, which reduces the transport of sodium from the intracellular space in myocytes to the extracellular space. This mechanism contributes to digoxin’s hemodynamic, neurohumoral and electrophysiologic effects.

The American College of Cardiology’s (ACC) recent guidelines list Digoxin as a IIa indication while the European guidelines give it a IIb recommendation for reducing heart failure hospitalizations in patients with heart failure with reduced ejection fraction (HfrEF). But the data for this continued level of recommendations seems to be eroding.

Recent Medical Trials Cause Concern

In a 2017 Swedish trial, among 2,723 patients with HFrEF and paroxysmal afib, Digoxin was associated with a 29% increase in the risk of mortality and no effect on hospitalization.

Additionally of the 18,201 patients enrolled in the ARISTOTLE trial,

• 17,897 patients had data available on heart failure status and Digoxin use during the trial
• 6,693 patients had heart failure at the time of trial enrollment
• 5,824 patients were on Digoxin at the start of the trial
• 4,434 patients had their blood levels of Digoxin measured at baseline

Each patient taking Digoxin was compared with three matched control patients from the trial who were not taking the drug.

Patients not taking Digoxin before the trial who began taking it over the course of the study had a 78 percent increase in the risk of death from any cause and a four-fold increased risk of sudden death after starting Digoxin use. Most sudden deaths occurred within six months after Digoxin was started.

A Potential Drug of the Past

In the past heart failure studies of Digoxin use that initially gained favor in the medical field, the rates of use of beta blockers, ACE-inhibitors, ARBs, mineralocorticoid receptor antagonists were lower than current daily medical therapy. Thus demonstrating a shift in recommend medical therapy.

Time will tell, but we may be nearing a point where digoxin use for heart failure and atrial fibrillation is a drug of the past.

Bryan Heart: A Leader in Heart Failure and Afib Treatment

Bryan Heart continues to stay on the leading edge of medical research adaptation to ensure our patients are provided the more effective care for the best possible outcomes.

For more information on heart failure and afib treatment or to refer a patient, contact Bryan Heart at 402-483-3333.