54 A year in the life of digoxin

IntroductionRecent decades have heralded remarkable advances in heart failure (HF) pharmacotherapy. Consequently, defining digoxin’s role amongst the array of contemporary compounds is challenging. Associated debate is mired in divisive opinion and ambiguous data. The ESC lends a class IIb recommendation for digoxin’s use in HFrEF patients who remain symptomatic despite Optimal Medical Therapy (OMT) and class IIa for rate control in atrial fibrillation (AF), where 1st line agents are inadequate or contraindicated.PurposeThe DIG Trial demonstrated that digoxin reduced hospitalisations, but not mortality in HFrEF patients in sinus rhythm, underpinning current guidelines. Subsequent observational data is contradictory. Although digoxin prescription has diminished, recent HF trials reveal that 10–20% patients continue to receive it. This prompted us to examine its usage at a large HF unit.MethodsThis was a single centre, retrospective, observational study conducted at St. Michael’s HF Unit, Dublin. Patients were identified by scanning the unit’s database for active digoxin prescriptions, specifically for de novo prescriptions in 2021, along with pre-existing ones. The database provided information on demographics, HF status, medications, comorbidities, echo parameters, lab values and a detailed clinical summaries. Data was stored on a password-protected file on-site. Analysis in the form of descriptive statistics was performed on Stata IC software. Regarding missing data, complete case analysis was employed, as data was complete for >90% patients.Results236 active prescriptions for digoxin were identified, 66 of these being issued in 2021. 219 patients were included in the final analysis. This was an elderly, symptomatic (88% ≥NYHAII) and comorbid population. 22.4% had experienced decompensated HF in the preceding year. 92.7% had AF. Correspondingly, rate control was the primary indication for digoxin in 84.5% of patients, with three distinct contexts: an adjunct where beta blocker (BB)/calcium channel blocker (CCB) was maximally dosed (50.7%); where hypotension precluded higher BB/CCB doses (16.9%); where contraindications/intolerances to BB/CCB existed (16.9%). In the remainder (32/219, 14.6%), the main rationale for prescription was HF. In this setting, digoxin was used to facilitate OMT in hypotension (7.3%), to tackle persistent symptoms in stable patients (4.1%) and in cases of unstable deterioration (3.2%). Amongst these 32 patients, 34.4% did not have