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Increased Mortality with Digoxin in AF

The use of digoxin in patients with Atrial Fibrillation (AF) is being called into question. A new study suggests it is associated with a significant increase in all-cause mortality.
The study, a special analysis of the AFFIRM trial, that controlled for multiple comorbidities, found an overall 41% increase in all-cause mortality in patients taking digoxin vs those not taking digoxin. The increase in all-cause mortality was consistently observed in men and women and in patients with and without underlying heart failure.
The use of digoxin has previously been associated with an increased risk of death in AF patients, but it has not been known whether this is because it tends to be used in sicker patients. A major randomized trial of digoxin in Heart Failure (the DIG-trial) showed an overall neutral effect on mortality, although death was increased in patients taking high-dose digoxin. However, hospitalizations for heart failure were reduced, and the consensus is that digoxin is beneficial in heart failure.

These new results should make doctors think hard about whether to prescribe digoxin for Atrial Fibrillation patients, especially if they don’t also have heart failure.
If patents have AF and heart failure, it is still reasonable to use digoxin. Theoretically, digoxin should be the perfect drug for patients with both conditions, as it slows the heart rate, which is needed in AF, and we know from the DIG trial that it has benefits in heart failure. But I would caution that low doses should be used and blood levels should be carefully monitored, as digoxin can interact with many different drugs.
Digoxin’s time as a first-line agent in Atrial Fibrillation patients without heart failure is over. In this group, the only benefit of digoxin is to slow the heart rate, which many other drugs can do better and more safely. So I would advise against using digoxin in such patients, unless beta blockers or calcium antagonists are not appropriate, maybe because of low blood pressure. And again, if it is used, stick to low doses with careful monitoring. Currently, 30% to 50% of AF patients are taking digoxin, more in some developing countries,

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perhaps a bit less in the US and Europe. This study brings some warnings that digoxin’s time as a first-line agent in AF patients without heart failure is over.

Reference: Eur Heart J. 2012 Nov 27.