Management: digoxin and other inotropes, β blockers, and antiarrhythmic and antithrombotic treatment

doi:10.1136/bmj.320.7233.495

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C R Gibbs,
M K Davies,
G Y H Lip

Digoxin

Use of digoxin for heart failure varies between countries across Europe, with high rates in Germany and low rates in the United Kingdom. It is potentially invaluable in patients with atrial fibrillation and coexistent heart failure, improving control of the ventricular rate and allowing more effective filling of the ventricle. Digoxin is also used in patients with chronic heart failure secondary to left ventricular systolic impairment, in sinus rhythm, who remain symptomatic despite optimal doses of diuretics and angiotensin converting enzyme inhibitors, where it acts as an inotrope.

Digoxin should be considered in patients with sinus rhythm plus (a) continued symptoms of heart failure despite optimal doses of diuretics and angiotensin converting enzyme inhibitors; (b) severe left ventricular systolic dysfunction with cardiac dilatation; or (c) recurrent hospital admissions for heart failure

Incidence of death or admission to hospital due to worsening heart failure in two groups of patients: those receiving digoxin and those receiving placebo (Digitalis Investigation Group's study—see key references box at end of article)

Study of effect of digoxin on mortality and morbidity in patients with heart failure*

Number of participants: 6800

Design: prospective, randomised, double blind, placebo controlled

Participants: left ventricular ejection fraction <45%

Intervention: randomised to digoxin (0.125-0.500 mg) or placebo; follow up at 37 months

Results:

Reduced admissions to hospital owing to heart failure (greater absolute and relative benefits in the patients with resistant symptoms and more severe impairment of left ventricular systolic function)
No effect on overall survival

Evidence of symptomatic benefit from digoxin in patients with chronic heart failure in sinus rhythm has been reported in several randomised placebo controlled trials and several smaller trials. The RADIANCE and PROVED trials, for example, reported that the withdrawal of digoxin from patients with congestive heart failure who had already been treated with the drug was associated with worsening heart failure and increased hospital readmission rates. The Digitalis Investigation Group's …