Digoxin in cardiac failure

Digoxin improves symptoms in patients with heart failure.

Digoxin in combination with ACE inhibitors has been shown to reduce the risk of hospital admission for worsening HF, but has no effect on mortality rates in HF (1).

In patients with HF and atrial fibrillation, digoxin

• could be used in rapid atrial fibrillation for the initial control of ventricular rate and may be useful in decompensated HF before starting beta blockers (1)
• is not useful in controlling the ventricular rate during exercise (1)

NICE recommends digoxin for use in patients with atrial fibrillation and heart failure, or those in whom symptoms are progressing on ACE inhibitors, beta-blocker and diuretic therapy (2).

• digoxin is recommended for:
  • worsening or severe heart failure due to left ventricular systolic dysfunction despite first- and second-line treatment for heart failure - seek specialist advice before initiating
    
    
• routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8-12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence
  
  
• serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the 'therapeutic range'

Patients who are on digoxin with concurrent beta blockers, digoxin should be discontinued if excessive bradycardia occurs (3).

Reference:

• (1) European Society of Cardiology (ESC) 2008. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008
• (2) NICE (September 2018). Chronic heart failure
• (3) Scottish Intercollegiate Guidelines Network (SIGN) 2007. Management of chronic heart failure: a national clinical guideline
• (4) The Digitalis Intervention Group (1997). The effect of digoxin on mortality and morbidiy in patients with heart failure. NEJM, 336, 525-33