Friday, September 20, 2013


Digoxin had been with us since the 18th century. It was William Withering in 1785 ( I think ), who published the historical paper ," An Account of the Foxglove and some of its Medical Uses With Practical Remarks on Dropsy and Other Diseases". The account given was that in patients with dropsy ( severe edema ), sounds like from systolic heart failure, digoxin made the edema disappear and the patient better. So it worked for many patients.
Then came the era of ACEI for heart failure and we began to acknowledge that some drugs for heart failure improved symptoms and some improved symptoms and also outcomes ( prognosis ). In the case of digoxin, it did not improve outcomes but it did improve symptoms and patients had fewer repeat hospitalisation. So digoxin did appear in many CPG guidelines as a second line drug for heart failure.
Well, a September 10, 2013 paper by Dr James Freedman may have put a stop to that as well. Pubished in the Circulation : Quality and outcomes, Sept issue, Dr Freedman of Stanford, studied 2991 patients with systolic heart failure. In about 18% of the patients ( 529 pts ), he gave them digoxin on top of standard heart failure therapy. This study was carried out from 2006-2008. After about 2.5 years of follow-up, there was a 72% increase in all cause mortality in those who were given digoxin, when compared to those who did not receive digoxin. There was also no difference in re-hospitalisation rates. It also did not matter whether the patients were  receiving  beta blockers or not.
What this means essentially is that digoxin may be harmful and carries an increase risk of dying. The cause of death was not listed in this paper. We can only speculate that the cause of death may have been arrhythmic. 
It looks like we should no longer use digoxin. Be it in heart failure or in the control of atrial fibrillation. There is a very real risk of dying.

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