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Challenges for the Basis of Practice

The Role of Digoxin in the Treatment of Heart Failure

Christopher W. May, MD and Marco N. Diaz, MD

From the Division of Cardiac Services, Maine Medical Center, Portland, Me.

Correspondence to Christopher W. May, MD, Division of Cardiac Services, Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102. E-mail cmay0001{at}maine.rr.com

Key Words: heart failure • digoxin • treatment

Digoxin and diuretics were once the cornerstones of therapy for patients with chronic heart failure. During the past 2 decades, an increasing number of therapeutic options for the treatment of symptomatic heart failure has emerged. Demonstrated benefit of these therapies has led to parallel growth of practice guidelines and performance measures. As a result, physicians caring for patients with heart failure face the increasing challenge of introducing and titrating multiple medications to achieve the perceived benefit promised by clinical trials while adhering to guideline-driven treatment algorithms.

The role of digoxin in the treatment of heart failure is long and storied, with the Digitalis Investigation Group (DIG) trial a relatively recent addition.¹ Currently, the addition of digoxin for the treatment of stage C heart failure is a 2B (level of evidence B) recommendation.² The DIG trial itself is still undergoing reinterpretation, particularly for subgroups defined by gender or clinical severity. However, the patients in the DIG trial may no longer reflect the heart failure population today, which has been reshaped by β-blockers, aldosterone antagonists, and devices to resynchronize contraction and prevent sudden death. Furthermore, the serum digoxin concentrations of many of the patients in the DIG study exceeded current recommendations. With this in mind, when should digoxin be added to the treatment of patients with decompensated systolic heart failure? Should dosing be guided by digoxin serum concentrations? Clinical studies have suggested increased hospitalizations and all-cause mortality when discontinuing chronic digoxin therapy in stable patients. Once started, when should digoxin be discontinued in patients with improved left ventricular function and stable symptoms?^3,4

	References

Top References

 
1. The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group. N Engl J Med. 1997; 336: 525–533.[Abstract/Free Full Text]

2. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, C. SS, Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to update the 2001 guidelines for the evaluation and management of heart failure)—developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005; 112: e154–e235.[Free Full Text]

3. Ahmed A, Gambassi G, Weaver MT, Young JB, Wehrmacher WH, Rich MW. Effects of discontinuation of digoxin versus continuation at low serum digoxin concentrations in chronic heart failure. Am J Cardiol. 2007; 100: 280–284.[CrossRef][Medline]

4. Adams KF Jr, Gheorghiade M, Uretsky BF, Patterson JH, Schwartz TA, Young JB. Clinical benefits of low serum digoxin concentrations in heart failure. J Am Coll Cardiol. 2002; 39: 946–953.[Abstract/Free Full Text]

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EDITOR’S NOTE

Challenges for the Basis of Practice will be a regular feature of Circulation: Heart Failure (see Stevenson LW. Challenges for the basis of practice in heart failure. Circ Heart Fail. 2008;1:81–83). It is designed to provide a forum for presentation and discussion of decisions arising commonly during the care of individual patients. The essence of "practice" in the context of medicine is best defined by its earliest meaning, "actual application of a plan or method, as opposed to the theories relating to it," from the Greek work "praktikos," meaning "concerned with action" (see Compact Oxford English Dictionary. Oxford, United Kingdom: Oxford University Press; 2005). Each day, most of the questions that must be answered in real time are unanswered by clinical trials, and many are unanswered even by those guidelines with level of evidence C, on which expert consensus has been reached from clinical experience without a randomized basis of evidence.

A Challenge to Practice topic can be submitted, in 500 words or less, by up to 5 clinicians, who can include physicians and/or nurses and will be cited as authors. After selection of the topic, a recognized expert consultant will be invited to review his or her own practical approach to the question.

The first topic selected was the use of digoxin in contemporary practice, as well-summarized by Drs May and Diaz from Portland, Me. The challenge was accepted by Dr Gary Francis, widely recognized as a master clinician as well as a scientist contributing profoundly to our understanding of the pathophysiology of heart failure.

Readers are invited to submit brief responses after publication of the question and expert review. These may describe personal clinical experience or practical lessons gleaned from published literature and should be identified as "Challenge Response" when submitted. Representative views will be selected for publication in excerpt form in subsequent issues. Although many controversies cannot be fully resolved with current experience, we are confident that this forum will stimulate observation and provide reassurance that we do not practice alone, but within a dedicated community.

	Footnotes

 
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

This article is Part I of a 2-part article. Part II appears on page 208.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by May, C. W. Articles by Diaz, M. N. Search for Related Content PubMed PubMed Citation Articles by May, C. W. Articles by Diaz, M. N. Related Collections Cardio-renal physiology/pathophysiology Other heart failure Other Treatment