Challenges for the Basis of Practice The Role of Digoxin in the Treatment of Heart Failure

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 -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