What is the role of digoxin (digitalis) in managing atrial fibrillation (AFib) in patients with heart failure with preserved ejection fraction (HFpEF)?

From the Guidelines

Digoxin should not be used as a first-line agent for rate control in patients with atrial fibrillation (AFib) and heart failure with preserved ejection fraction (HFpEF), but may be considered as a second or third-line agent when other medications have failed or are contraindicated. The role of digoxin in managing AFib in patients with HFpEF is limited, and its use should be individualized based on patient-specific factors, such as kidney function, age, and comorbidities 1.

Key Considerations

• The typical starting dose of digoxin is 0.125-0.25 mg daily, with lower doses recommended for elderly patients or those with impaired kidney function 1.
• Digoxin helps control ventricular rate by increasing vagal tone and slowing conduction through the AV node, but unlike beta-blockers or calcium channel blockers, it does not reduce exercise heart rate effectively 1.
• Blood levels should be monitored regularly, aiming for a therapeutic range of 0.5-0.9 ng/mL, as toxicity can occur at higher levels 1.
• Common side effects include nausea, visual disturbances, and confusion, and digoxin requires careful monitoring in patients with kidney dysfunction and has numerous drug interactions, particularly with amiodarone, verapamil, and certain antibiotics 1.

Clinical Evidence

• A recent study found that digoxin may be effective in controlling heart rate in patients with AFib and HFpEF, with similar quality of life outcomes compared to beta-blockers 1.
• However, another study found that higher doses of digoxin are associated with increased mortality, highlighting the need for careful dose titration and monitoring 1.
• The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation recommends the use of digoxin as a second or third-line agent for rate control in patients with AFib and HFpEF 1.

Recommendations

• Digoxin should be used with caution in patients with AFib and HFpEF, and only when other medications have failed or are contraindicated.
• Patients should be closely monitored for signs of toxicity, and blood levels should be regularly checked to ensure therapeutic ranges are maintained 1.
• The use of digoxin should be individualized based on patient-specific factors, and alternative treatments should be considered in patients with kidney dysfunction or other comorbidities 1.

From the FDA Drug Label

Digoxin is indicated for the treatment of mild to moderate heart failure. Digoxin increases left ventricular ejection fraction and improves heart failure symptoms as evidenced by exercise capacity and heart failure symptoms as evidenced by exercise capacity and heart failure-related hospitalizations and emergency care, while having no effect on mortality. Heart Failure: Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation.

The role of digoxin in managing atrial fibrillation (AFib) in patients with heart failure with preserved ejection fraction (HFpEF) is to control the ventricular response rate. However, the provided drug labels do not directly address the use of digoxin in patients with HFpEF.

• The labels discuss the use of digoxin in patients with heart failure and atrial fibrillation, but do not specify the type of heart failure (e.g., HFpEF or HFrEF).
• The labels do mention that digoxin is indicated for the treatment of mild to moderate heart failure, but do not provide information on its use in HFpEF specifically.
• Therefore, based on the provided information, no conclusion can be drawn about the effectiveness of digoxin in patients with HFpEF and AFib 2.

From the Research

Role of Digoxin in HFpEF Patients with AFib

• Digoxin may be useful in obtaining satisfactory rate control in combination with a beta-blocker in patients with atrial fibrillation (AFib) and heart failure with preserved ejection fraction (HFpEF) 3.
• However, digoxin does not improve survival in these patients 3, 4, 5, 6, 7.
• The initiation of digoxin was associated with a lower risk of heart failure readmission but had no association with mortality in hospitalized older patients with heart failure (HFrEF and HFpEF) and AFib 4.
• In older patients with HFpEF discharged after acute heart failure, digoxin treatment was associated with increased mortality and/or re-admission, particularly in patients with lower heart rates 5.
• Digoxin initiation prior to hospital discharge was not associated with 30-day or 6-year outcomes in older hospitalized patients with HFpEF 6.
• A systematic review and meta-analysis found that treatment with digoxin was associated with a neutral effect on all-cause mortality, all-cause hospitalization, HF hospitalization, and all-cause mortality or HF hospitalization in patients with HFpEF 7.

Key Findings

• Digoxin may help with rate control in HFpEF patients with AFib, but its effect on survival is neutral 3, 4, 7.
• The use of digoxin in HFpEF patients with AFib should be carefully considered, taking into account the patient's heart rate and other individual characteristics 5.
• More research is needed to fully understand the role of digoxin in managing HFpEF patients with AFib 4, 6, 7.