Should Digoxin Still Be Used in Patients With Atrial Fibrillation? Interview with:

Renato D. Lopes MD, MHS, PhD Duke University Medical Center Duke Clinical Research Institute Durham, NC 27705

Dr. Renato Lopes

Renato D. Lopes MD, MHS, PhD
Professor of Medicine, Division of Cardiology
Duke University Medical Center
Duke Clinical Research Institute
Terrace Level, Durham, NC 27705 What is the background for this study?

1-      Digoxin is used in ≈ 30% of patients with atrial fibrillation (AF) worldwide, despite the lack of randomized clinical trials to assess its efficacy and safety in this setting.
2-      Current AF guidelines recommend digoxin for rate control in patients with AF with and without heart failure (HF).
3-      There are no specific recommendations about serum digoxin concentration monitoring in the atrial fibrillation guidelines. What are the main findings?

  1. In patients with atrial fibrillation currently taking digoxin, the risk of death is independently related to digoxin serum concentration and is highest in patients with concentrations ≥1.2 ng/mL.
  2. Initiating digoxin is independently associated with higher mortality in patients with AF, regardless of heart failure. What should readers take away from your report?

  1. In the absence of randomized trial data showing its safety and efficacy, digoxin should generally not be prescribed for patients with atrial fibrillation, particularly if symptoms can be alleviated with other treatments.
  2. In patients with   already taking digoxin, monitoring its serum concentration may be important, targeting blood levels <1.2 ng/mL. What recommendations do you have for future research as a result of this work?

Response: Randomized trials are needed to assess the efficacy and safety of digoxin in patients with atrial fibrillation and confirm our findings. Is there anything else you would like to add? 

Response: Despite not being randomized, this study was an extensive and comprehensive exploration of the independent association between digoxin concentration and outcomes in the setting of AF. Therefore, given the lack of evidence of safety from randomized trials, the associations we describe may have a substantial impact on scientific guidelines and the treatment of patients with atrial fibrillation.


Digoxin and Mortality in Patients With Atrial Fibrillation
Renato D. LopesRoberto RordorfGaetano M. De FerrariSergio LeonardiLaine ThomasDaniel M. WojdylaPeter RidefeltJohn H. LawrenceRaffaele De CaterinaDragos VinereanuMichael HannaGreg FlakerSana M. Al-KhatibStefan H. HohnloserJohn H. AlexanderChristopher B. GrangerLars Wallentin and for the ARISTOTLE Committees and Investigators

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