UMEM Educational Pearls

Safety Risk? Digoxin in Atrial Fibrillation

- Digoxin is commonly utilize for atrial fibrillation/flutter with rapid ventricular response, though beta blockers and/or calcium channel blockers are a better 1st line therapy given digoxin’s narrow therapeutic index and lack of mortality benefit.

- Digoxin in the acute setting is often favored given its ability to reduce the heart rate while maintaining or slightly augmenting blood pressure.

- 2014 AHA/ACC guidelines recommend digoxin, specifically for rate control in patients with heart failure and/or reduced ejection fraction.

- There have been 2 post hoc studies from the AFFIRM trial which showed conflicting results w/regards to digoxin and risk of mortality.

1.     Increased risk of mortality associated w/digoxin (on-treatment analytic strategy)

2.     No association w/mortality (intent-to-treat analytic strategy)

- A recent retrospective cohort examination of newly diagnosed afib patients without heart failure & no prior use of digoxin; digoxin was independently associated with a 71% higher risk of death & a 63% higher risk of hospitalization.

- Consistent and substantial increase in mortality and hospitalization risk was seen using both on-treatment and intent-to-treat analytic methods.

- Given other available rate control options, digoxin should be used with caution.



Freeman J, Reynolds K, et al. Digoxin and Risk of Death in Adults With Atrial Fibrillation The ATRIA-CVRN Study. Circ Arrhythm Electrophysiol. 2015;8:49-58.