Letter to the Editor

Digoxin: Time to Reconsider Its Role in Atrial Fibrillation?

Authors: Mohit K. Turagam, MD, MS


To the Editor:

Digoxin is one of the oldest drugs available and has been used extensively in heart failure and the control of ventricular rate for atrial fibrillation (AF). The recently published propensity-adjusted analysis of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial demonstrated that digoxin is associated with a 41% increase in mortality (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.19–1.67; P < 0.001), cardiovascular mortality (HR 1.35, 95% CI 1.06–1.71; P = 0.016), and arrhythmic mortality (HR 1.61, 95% CI 1.12–2.30; P = 0.009)1 when prescribed for AF after controlling for other comorbidites (including with and without heart failure).1 Are these results relevant to clinical practice? There are a few potential explanations for these results.

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1. Whitbeck MG, Charnigo RJ, Khairy P, et al. Increased mortality among patients taking digoxin—analysis from the AFFIRM study. Eur Heart J. 2012;Nov 27 [Epub ahead of print]
2. Kelly RA, Smith TW. Recognition and management of digitalis toxicity. Am J Cardiol. 1992; 69: 108G–118G.
3. Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med. 1997; 336: 525–533.
4. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002; 347: 1825–1833.
5. Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010; 362: 1363–1373.