title: [Digitalis, a drug to be scrapped?]
abstract: We performed a comprehensive review of the scientific literature on the use of digoxin in heart failure and atrial fibrillation. In congestive heart failure (CHF) there is only one randomized trial with a statistical sample sufficiently large. In this trial (DIG trial), which enrolled patients with systolic left ventricular dysfunction in sinus rhythm, digoxin had a neutral action on mortality and modestly reduced the overall need of hospitalization. The study was conducted in the pre-beta-blocker era and, therefore, it has a doubtful application to the current clinical context. There are no randomized trials on atrial fibrillation, either with or without heart failure. Several observational and retrospective studies and meta-analysis have shown an association between the use of digoxin and increased mortality about 20%. Both in the European and American guidelines, even in class I recommendations, evidence is not supported by randomized or observational trials, but just by experts' opinions. Digoxin use in CHF and atrial fibrillation is related to the physician's clinical judgment, based more on consolidated custom that on established scientific evidence. In our opinion, this therapy should be withdrawn until new randomized controlled trials will provide evidence of its efficacy. Two trials have been planned to this aim. Also the issue of toxicity threshold is still unresolved; digoxinemia values should be <1 ng/ml if digoxin is used, to avoid overdosing and toxicity with increased mortality.
authors.affiliation: Dipartimento Cardiovascolare e Neurologico, Cardiologia Valdichiana, USL 8, Arezzo.
authors.forename: Franco
authors.initials: F
authors.lastname: Cosmi
authors.affiliation: Dipartimento Cardiovascolare e Neurologico, Cardiologia Valdichiana, USL 8, Arezzo.
authors.forename: Barbara
authors.initials: B
authors.lastname: Tarquini
authors.affiliation: Dipartimento Cardiovascolare e Neurologico, Cardiologia Valdichiana, USL 8, Arezzo.
authors.forename: Beatrice
authors.initials: B
authors.lastname: Mariottoni
authors.affiliation: Dipartimento Cardiovascolare e Neurologico, Cardiologia Valdichiana, USL 8, Arezzo.
authors.forename: Deborah
authors.initials: D
authors.lastname: Cosmi
mesh_terms: D001281:Atrial Fibrillation / Q000188:drug therapy*; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D004071:Digitalis Glycosides / Q000627:therapeutic use*; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D017410:Practice Guidelines as Topic
chemical_list: D002316:Cardiotonic Agents; D004071:Digitalis Glycosides