From the Guidelines
Digoxin is not recommended for patients with a heart rate less than 60 beats per minute due to its potential to worsen bradycardia and increase the risk of dangerous complications. The use of digoxin in patients with bradycardia is generally contraindicated because the drug can further decrease heart rate by slowing conduction through the atrioventricular (AV) node, potentially leading to complete heart block or asystole 1. Key considerations for the use of digoxin include:
- The drug's negative chronotropic effects, which can exacerbate bradycardia
- The potential for increased risk of digitalis toxicity in patients with impaired renal function, low lean body mass, or those taking other medications that can affect digoxin levels 1
- The importance of monitoring serum digoxin levels and adjusting the dose accordingly to minimize the risk of toxicity
- The need for alternative medications or treatments in patients with bradycardia who require therapy for underlying conditions such as heart failure. In patients with heart failure, digoxin is commonly initiated and maintained at a dose of 0.125 to 0.25 mg daily, with lower doses recommended for patients over 70 years old, those with impaired renal function, or those with a low lean body mass 1. However, in the context of bradycardia, the potential risks associated with digoxin use outweigh any potential benefits, and alternative treatments should be considered to minimize the risk of adverse outcomes.
From the FDA Drug Label
Because digoxin slows sinoatrial and AV conduction, the drug commonly prolongs the PR interval. The drug may cause severe sinus bradycardia or sinoatrial block in patients with pre-existing sinus node disease and may cause advanced or complete heart block in patients with pre-existing incomplete AV block In such patients consideration should be given to the insertion of a pacemaker before treatment with digoxin
Digoxin is not safe to use in patients with bradycardia (heart rate less than 60 beats per minute) as it may worsen the condition by causing severe sinus bradycardia or sinoatrial block. Consideration should be given to the insertion of a pacemaker before treatment with digoxin in such patients 2.
From the Research
Digoxin Use in Bradycardia
- Digoxin is not typically used to treat bradycardia (heart rate less than 60 beats per minute) as it can worsen the condition 3.
- The primary treatment for symptomatic bradycardia is atropine, and percutaneous pacing can be used as a bridge to definitive treatment, which is the placement of a permanent pacemaker 3.
Digoxin Use in Atrial Fibrillation
- Digoxin can be used to control ventricular rate in patients with atrial fibrillation (AF) and heart failure (HF) 4, 5.
- However, digoxin does not improve survival in patients with AF and HF, but it may help achieve satisfactory rate control in combination with a beta-blocker 4, 5.
- Digoxin may be useful in patients with AF and HF who have hypotension or an absolute contraindication to beta-blocker treatment 4.
Safety of Digoxin in Patients with Heart Failure
- Digoxin use is not associated with increased mortality in patients with AF and HF when used for rate control 5.
- However, digoxin is associated with increased all-cause mortality in patients with AF without HF 5.
- A study found that digoxin use in the emergency department to treat patients with acute heart failure is safe and not associated with increased short-term mortality 6.