Low-dose digoxin in patients with heart failure with reduced or mildly reduced ejection fraction: a randomized...

Digoxin is the oldest drug in cardiovascular medicine, but its value in the current management of heart failure is unclear. Earlier studies have suggested that low-dose digoxin might be beneficial, but evidence from rigorous randomized clinical trials is lacking. In this double-blind, placebo-controlled trial (the DECISION trial), 1,001 patients with symptomatic chronic heart failure and a left ventricular ejection fraction of 50% or less were randomized to low-dose digoxin or placebo, with a target serum digoxin concentration of 0.5-0.9 ng ml^-1. The mean age of the participants was 72 ± 9 years, 28% were women and 29% had atrial fibrillation. The primary outcome was a composite of total worsening heart failure events, defined as total hospitalizations or total urgent hospital visits for worsening heart failure and cardiovascular mortality. Over a median follow-up of 36.5 months, 238 primary-outcome events occurred in 131 of 500 patients in the digoxin group, and 291 primary-outcome events in 152 of 501 patients occurred in the placebo group (rate ratio 0.81; 95% confidence interval (CI) 0.61-1.07, P = 0.133). The total number of worsening heart failure events was 155 and 203 in the digoxin and placebo groups, respectively (rate ratio 0.76, 95% CI 0.54-1.05) and cardiovascular mortality occurred in 83 patients (17%) and 88 (18%) in the digoxin and placebo groups, respectively (hazard ratio 0.93, 95% CI 0.69-1.26). Low-dose digoxin was generally well tolerated and safe, and results were similar between men and women. The results of this trial indicate that in patients with heart failure and reduced or mildly reduced ejection fraction, low-dose digoxin did not significantly reduce the composite endpoint of total worsening heart failure events or cardiovascular mortality. ClinicalTrials.gov registration: NCT03783429 .