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Digoxin: The good and the bad
Oliver J Ziff1, Dipak Kotecha2
1Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Institute of Cardiovascular Science, University College London, London, UK.
Insights
Digitalis, used for over 200 years, is a key treatment for atrial fibrillation and heart failure. A meta-analysis shows digoxin has a neutral effect on mortality, challenging older data.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Digitalis has been used for over 230 years for treating atrial fibrillation and heart failure.
- While beneficial for reducing hospital admissions in heart failure, robust trial data, especially for atrial fibrillation, is lacking.
- Observational studies often overlook that digitalis is typically a second-line therapy for critically ill patients.
Purpose of the Study:
- To evaluate the evidence base for cardiac glycosides.
- To provide a pragmatic guide to the advantages and disadvantages of digitalis therapy.
Main Methods:
- A comprehensive meta-analysis of all available digoxin studies was conducted.
- Evidence base for cardiac glycosides was reviewed.
Main Results:
- The meta-analysis demonstrated a neutral effect of digoxin on mortality.
- This finding contrasts with prior observational data.
Conclusions:
- Digitalis remains an important therapy for atrial fibrillation and heart failure.
- Clinical use requires careful consideration of dosage, serum concentration, drug interactions, and side effects.
Abstract:
After 230 years of use, digitalis remains an important and useful therapy for patients with atrial fibrillation, heart failure, and the 30-50 % of patients with both conditions. Although the combination of positive inotropic activity with negative chronotropic effects has been shown to reduce hospital admissions in heart failure, there is a distinct lack of robust trial data, particularly in patients with atrial fibrillation. We recently performed a comprehensive meta-analysis of all digoxin studies and demonstrated a neutral effect on mortality. This contradicts prior observational data that overlook the fact that digitalis is usually given as second-line therapy to the sickest patients. Use of these agents in clinical practice should take account of appropriate dose, serum concentration, drug interactions, and potential side effects. The aim of this review is to evaluate the evidence base for cardiac glycosides and provide a pragmatic guide to their advantages and disadvantages.
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