Is digoxin (digitalis glycoside) contraindicated in all degrees of atrioventricular (AV) block?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: March 4, 2025 • View editorial policy

From the Guidelines

Digoxin is not contraindicated in all degrees of atrioventricular (AV) block, but its use is cautioned against in patients with significant sinus or atrioventricular block, unless the block has been addressed with a permanent pacemaker. The decision to use digoxin in patients with AV block should be made on a case-by-case basis, considering the severity of the block and the presence of other comorbidities. According to the 2013 ACCF/AHA guideline for the management of heart failure 1, patients should not be given digoxin if they have significant sinus or atrioventricular block unless the block has been addressed with a permanent pacemaker.

When considering the use of digoxin in patients with AV block, it is essential to weigh the potential benefits against the risks. The drug can be useful in controlling ventricular response in patients with atrial fibrillation, but it should be used cautiously in patients taking other drugs that can depress sinus or atrioventricular nodal function or affect digoxin levels. Key considerations include:

  • The severity of the AV block: Digoxin should be avoided in patients with second-degree Mobitz type II heart block, complete (third-degree) heart block, and severe sinus node dysfunction, especially when not protected by a functioning pacemaker.
  • The presence of a permanent pacemaker: If the block has been addressed with a permanent pacemaker, digoxin can be considered.
  • Close monitoring: Regular ECG monitoring is recommended when digoxin is used in patients with any degree of heart block, and the lowest effective dose should be employed.
  • Patient education: Patients should be educated about signs of digoxin toxicity, including new or worsening bradycardia, visual disturbances, nausea, and confusion, as noted in the guidelines 1.

In summary, while digoxin is not contraindicated in all degrees of AV block, its use requires careful consideration of the individual patient's condition and close monitoring to minimize the risk of adverse effects. The most recent and highest quality study, the 2013 ACCF/AHA guideline for the management of heart failure 1, provides the basis for these recommendations.

From the FDA Drug Label

Digitalis glycosides are contraindicated in patients with ventricular fibrillation or in patients with a known hypersensitivity to digoxin. Therapeutic doses of digoxin may cause heart block in patients with pre-existing sinoatrial or AV conduction disorders; heart block can be avoided by adjusting the dose of digoxin

The FDA drug label does not explicitly state that digoxin is contraindicated in all degrees of atrioventricular (AV) block. However, it does mention that therapeutic doses of digoxin may cause heart block in patients with pre-existing sinoatrial or AV conduction disorders, and that the dose can be adjusted to avoid heart block.

  • Contraindications for digoxin are listed as ventricular fibrillation and known hypersensitivity to digoxin 2.
  • Pre-existing AV conduction disorders may require careful dose adjustment to avoid heart block 3. The information provided does not support a conclusion that digoxin is contraindicated in all degrees of AV block.

From the Research

Digoxin Contraindications

  • Digoxin is not indicated for patients with significant sinus or atrioventricular block, unless the block has been treated with a permanent pacemaker 4
  • The drug should be used cautiously in patients who receive other agents known to depress sinus or atrioventricular nodal function, such as amiodarone or a beta-blocker 4

Atrioventricular Block Considerations

  • A study from 1971 found that digoxin did not precipitate a return to second- or third-degree heart block in patients with known disease of their conduction tissue, despite therapeutic levels of digoxin 5
  • However, the 2003 study recommends that digoxin should not be administered to patients who have significant sinus or atrioventricular block, unless the block has been treated with a permanent pacemaker 4

Clinical Use of Digoxin

  • Digoxin remains useful in the management of chronic heart failure, and its clinical efficacy can no longer be doubted 4
  • The drug has a substantial benefit in reducing heart failure hospitalizations, and its safety has been verified by the multicenter DIG trial 4
  • However, the prescription rates of digoxin have been declining since the institution of β-blockers and aldosterone antagonists as part of modern heart failure medical therapy 6

References

4
Research

Digoxin remains useful in the management of chronic heart failure.

The Medical clinics of North America, 2003

5
Research

Effect of digoxin on A-V conduction.

British medical journal, 1971

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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