Concerns about the use of digoxin in acute coronary syndromes

Area of Science:

• Cardiology
• Clinical Pharmacology
• Outcomes Research

Background:

• Digitalis, including digoxin, has a controversial history in cardiovascular medicine.
• Acute coronary syndromes (ACSs) frequently present with or precipitate heart failure (HF).
• The role of digoxin in ACS patients with HF requires further clarification.

Purpose of the Study:

• To investigate the association between digoxin use and clinical outcomes in hospitalized patients with ACS complicated by HF.
• To examine potential sex differences in the relationship between digoxin and mortality.
• To assess the impact of prior heart disease on digoxin's effect in this patient population.

Main Methods:

• Analysis of data from the International Survey of Acute Coronary Syndromes Archives registry (NCT04008173).
• Inclusion of patients with acute heart failure (Killip class ≥2) presenting with ACS.
• Use of inverse probability of treatment weighting (IPTW) models to estimate treatment effects on 30-day all-cause mortality.

Main Results:

• Of 25,187 patients, 18.7% received digoxin.
• Digoxin use was associated with increased 30-day mortality in both women (RR: 1.24) and men (RR: 1.20).
• These associations persisted across subgroups, including those without prior coronary heart disease and those in sinus rhythm.

Conclusions:

• Digoxin therapy is linked to an elevated risk of early death in patients experiencing ACS with HF.
• The findings underscore the necessity of re-evaluating digoxin's clinical application in ACS management.
• Sex and prior cardiac history did not mitigate the observed increased mortality risk associated with digoxin.