Digoxin may be useful in the treatment of patients with AHF, although it is not considered first-line treatment. This drug has vagomimetic effects and reduces the activity of the renin-angiotensin system and systemic venous resistance and increases cardiac output. Although the guidance of the European Society of Cardiology considers the use of digoxin in AAI to control heart rate, especially in the presence of acute atrial fibrillation, the guidelines of the American Heart Association and the Heart Failure Society of America do not indicate their use. There have not yet been studies in which clinical results have been examined to determine the favorable therapeutic effect of digoxin on ACE. is currently associated with an increase in the mortality of patients with heart failure, which has limited its use

https://academic.oup.com/eurheartj/article/36/28/1831/2398087/Digoxin-associated-mortality-a-systematic-review#84317416

https://secardiologia.es/multimedia/blog/6471-digoxina-aumento-mortalidad-debemos-cambiar-practica-clinica

http://linkinghub.elsevier.com/retrieve/pii/S0014256511001834

Dr. Luis del Carpio Orantes

Thanks a lot Luis for your reply!

It is considered that digoxin may be indicated in HF patients with atrial fibrillation for better heart rate control. This is true if it concern i/v  digoxin during  in-hospital stay.

What about usefulness and terms of digoxin use per os in HF patients with AF after discharge?

Dear Nataliia,

According to data of the systematic review and meta-analysis performed by O.Ziff et al. digoxin has a neutral effect on all cause mortality in randomised trials and is associated with a reduction in hospital admission. Among evaluation criteria of multiple effects of digoxin was hospital (re)admission rate that considers digoxin use per os as in out-patient settings. 

So, digoxin is used at home after discharge but with careful adhering to dosage, monitoring of not rare side effects taking into account the alteration of drug metabolisms in the elderly, in patients with chronic renal and liver disease. 

Please, read the appended article for detailed informationan about impact of digoxin on death and clinical outcomes across all observational and randomised controlled trials.

Best regards, G.T.

Trends in use of digoxin

Use of digoxin in the USA has declined substantially for treatment of congestive heart failure (Banerjee & Stafford, 2010) and of atrial fibrillation (Stafford et al., 1998; Fang et al., 2004). Trends in the European Union may have lagged behind those in the USA, but use for both conditions has declined (Sturm et al., 2007). Use of digoxin may have been reduced between 1991 and 2004 in the USA, but not in the United Kingdom (Haynes et al., 2008).

FDA reported that digitoxin and acetyldigitoxin are no longer manufactured in the USA (FDA, 2013).

Globally, there are 160 licensed products containing digoxin, while there are only seven licensed products containing digitoxin in Germany, Austria, Hungary, and Norway (Index Nominum, 2013).

Despite the introduction of new therapeutic strategies, cardiac glycosides are still widely used, and digoxin belongs to the 10 most frequently prescribed drugs in the USA (Albrecht & Geiss, 2000). In Estonia, the consumption of digoxin was very high in the times of the former Soviet Union and decreased in the first years of independence. When problems with drug availability were overcome, the use of digoxin increased by 35% in 1994–97 (Pähkla et al., 1999).

While a rare event, the homicidal use of digoxin has been described. Suicide by digoxin may have been more frequent in continental Europe, but has also occurred in the USA and England (Burchell, 1983).

Total worldwide sales of digoxin were US$ 142 million in 2012, with 33% occurring in the USA (US$ 47 million). Other nations reporting appreciable use of digoxin included Japan (US$ 14 million), Canada (US$ 11 million), and the United Kingdom (US$ 9 million) (IMS Health, 2012a).

In the USA in 2012, digoxin was reported by office-based physicians in 1.85 million drug uses, and was being taken by approximately 700 000 patients (IMS Health, 2012b). According to the IMS Health National Prescription Audit Plus, there were a total of 9.6 million prescriptions for digoxin in 2012, down from 14.6 million prescriptions in 2008 (IMS Health, 2012c).

Most commonly reported clinical indications for digoxin in the USA, 2011–2012

A very wonderful question, but not within my specialty and the authors of this greetings

Summary of meta-analyses for all cause mortality in observational and randomised studies on safety and efficacy of digoxin, comprising 999 994 participants across 75 study analyses.

Hi Nataliia.. Digitalis can be used in systolic heart failure with atrial fibrillation. It has got some role in heart failure with preserved EF with atrial fibrillation. It may have some role in refractory heart failure with dilated heart in addition to beta blocker and other standard therapy. In our country In India still it is widely used with good results because it is very low cost drugs. It should be causously used in elderly, liver and renal dysfunction and hypokalemia should be avoided. In Rheumatic mitral stenosis with atrial fibrillation for rate controll digitalis is used in addition to beta blocker for long term with good results with few side effects in our country. Though study have failed to get mortality benefit with this drugs.. I think some new well designed studied are needed to know further wheather it has got any mortality benefit or any effect on reduction of rate of hospitalisation. 

Hi Biswajit! Thank You for answer about digoxine in real clinical practice in India. I agree with You that digoxine is used widely in patients with AF and HF, and because of it low price also.

What should be the terms of follow up of patients using digoxine after discharge to control side effects?

Hi Nataliia,,, In our country in young patient of Rheumatic mitral stenosis with AF to control heart rate we are using digitalis with betablockers for several years without side effects. We have to monitor serum potassium to avoid side effects. We generally used 0.25mg tablet per day. Dose of digitalis to be avoided one or two day of each week because of its long half life.. In elderly patients dose will be half and needs frequent monitoring of serum potassium. We have seen some GI side effects and bradycardia.. Serious life threatening arrhythmia is extremely rare.. Better not to use in patients of advanced renal and hepatic dysfunction.. Thanks 

Hi Biswajit! Thanks a lot of useful information.

Ace Inhibitors and Beta blockers , along with diuretics have become the important drugs in heart failure . The reason is that in cardiac failure , reduced cardiac output leads to sympathetic over activity & stimulation of renin - angiotensin -aldosterone system , leading to increased peripheral vascular resistance & tachycardia , which leads to further reduction of cardiac function & increased mortality . Therefore , these drugs lead to better long term survival . Digoxin gives symptomatic relief , but does not improve long term survival . But , digoxin is the only known oral cardiac inotrope & its role diminished in cardiac failure , after the advent of these drugs , except in atrial fibrillation . As Biswajit mentioned it is used in Rheumatic Mitral stenosis with AF in India & still has a role in cardiac failure .