Education And Debate

Recent Advances: Cardiology II: Treatment of heart failure and atrial fibrillation and arrhythmias

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6969.1631 (Published 17 December 1994) Cite this as: BMJ 1994;309:1631
  1. John McMurray
  1. Department of Cardiology, Western General Hospital, Edinburgh EH4 2XU, consultant.
  2. University Department of Medical Cardiology, Royal Infirmary, Glasgow G31 2ER, senior lecturer.
  1. Correspondence to: Dr McMurray.
  1. Andrew Rankin
  1. Department of Cardiology, Western General Hospital, Edinburgh EH4 2XU, consultant.
  2. University Department of Medical Cardiology, Royal Infirmary, Glasgow G31 2ER, senior lecturer.

    In the first part of our review of the advances in cardiology over the past year we considered treatment of myocardial infarction and angina.1 In this part we summarise the most important advances in the treatment of heart failure, atrial fibrillation, and arrhythmias. A glossary of study abbreviations is given in the appendix.

    Heart failure and digoxin

    In the past year, more has been learnt about what does not help patients with chronic heart failure than what is of benefit. Important American guidelines on treatment have also been issued.2

    Two trials have investigated whether digoxin is of benefit in patients with chronic heart failure who are in sinus rhythm.3 4 In both trials the condition was stabilised by digoxin treatment before patients were randomly allocated in a double blind fashion to withdrawal (placebo substitution) or continuation of digoxin. In one study (PROVED) patients were not treated with an angiotensin converting enzyme inhibitor whereas in the other (RADIANCE) they were. During follow up of three months the patients in both groups who had had digoxin withdrawn showed clinical deterioration (table I).

    View this table:
    Table I

    Outcomes after three months in trials of digoxin withdrawal in patients with chronic heart failure34

    The results of these trials are important advances in our understanding of the role of digoxin in chronic heart failure. For patients who remain symptomatic while taking a diuretic but cannot tolerate an angiotensin converting enzyme inhibitor, digoxin is an option. Similarly, patients who remain symptomatic despite taking an angiotensin converting enzyme inhibitor should also be treated with digoxin.

    The one caveat to these conclusions is whether deterioration after digoxin withdrawal (as seen in the studies) is the same as clinical improvement when the drug is added to existing drug treatment. Other studies suggest that the addition of digoxin to diuretics is of …

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