Contemporary use of digoxin in the management of cardiovascular disorders.

Digoxin Use in Cardiovascular Medicine: Past and Present Digitalis is the oldest compound in cardiovascular medicine that continues to be used in contemporary clinical practice.1 Evidence supporting the beneficial effects of digoxin on hemodynamic, neurohormonal, and electrophysiological parameters has been accumulated from 200 years of clinical experience and research (Table 1).2 Digoxin was approved for heart failure in 1998 under current regulations by the Food and Drug Administration on the basis of the Prospective Randomized Study of Ventricular Function and Efficacy of Digoxin (PROVED), Randomized Assessment of Digoxin on Inhibitors of the Angiotensin Converting Enzyme (RADIANCE), and Digitalis Investigators Group (DIG) clinical trials.3–5 It was also approved for the control of ventricular response rate for patients with atrial fibrillation. The most recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend digoxin for symptomatic chronic heart failure for patients with reduced systolic function (Class IIa recommendation: weight of evidence/opinion is in favor of usefulness/ efficacy), preserved systolic function (Class IIb: usefulness/ efficacy is less well established by evidence/opinion), and/or rate control for atrial fibrillation with a rapid ventricular response (Class IIa).6 The new Heart Failure Society of America guidelines for heart failure provide similar recommendations.7 Despite its relatively recent approval by the Food and Drug Administration and the guideline recommendations, digoxin use is decreasing in patients with heart failure.8 In the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) registry, only 30% of patients with left ventricular systolic dysfunction were being treated with digoxin before admission. Digoxin was added in only 8% of patients before discharge despite the fact that they had signs and symptoms of heart failure while receiving diuretics, ACE inhibitors, or angiotensin receptor blockers (ARBs) and -blockers.9,10 This decrease in digoxin use is likely the result of several factors. Digoxin has not been promoted by the pharmaceutical industry and has received little attention at national and international meetings. This may have been the result of the development and introduction of life-saving therapies for heart failure, including -blockers, ARBs, aldosterone blockers, and cardiac resynchronization therapy (CRT). Safety concerns about digoxin therapy–increased mortality in women also may have contributed to this decrease in its use.8,11 This update reevaluates the role of digoxin in the context of recent advances in heart failure therapy, provides practical recommendations for its use, and identifies areas for future research.