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	The Pharmaceutical Journal Vol 269 No 7219 p524 12 October 2002	This page Reprint Photocopy
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CHF

Confusion over use of digoxin

From Mrs D. Webbe, MRPharmS

With reference to the continuing professional development article (PDF 75K) "Chronic heart failure" (PJ, 7 September, pp325–7), I have been left with some confusion surrounding the use of digoxin in patients with CHF and normal sinus rhythm.

I understand that Mark Kearney, who wrote the above article in collaboration with Helen Williams, was also a co-author of a research letter previously published in The Lancet,¹ in which he alerted clinicians on the routine use of digoxin in CHF due to increased mortality associated with its use. This was substantiated by the results of two studies, the UK-HEART and the AIRE study,¹ which both demonstrated that digoxin use was an independent predictor of mortality and adverse prognosis in CHF. The PJ article seems, however, to suggest that digoxin may still be considered for patients remaining symptomatic despite optimised doses of diuretics, angiotensin-converting enzyme inhibitors, beta-blockers and spironolactone.

In view of that, please would the author(s) answer the following questions:

1. Is it really worth giving digoxin to multidrug-resistant CHF patients with sinus rhythm (who presumably are already very ill), given its overall adverse effect on mortality?

2. Before recommending its use with the associated potential hazards in such clinical settings, should we not first look for some evidence-based results?

References

1. Lindsay SJ, Kearney MT, Prescott RJ, Fox KA, Nolan J. Digoxin and mortality in chronic heart failure. UK Heart Investigation. Lancet 1999;354:1003.

Daniela Webbe
Benfleet, Essex

MARK KEARNEY and HELEN WILLIAMS reply:

Thank you for your interest in our article. The two articles that you refer to^1,2 were retrospective analyses of studies not specifically designed to explore the mortality benefit of digoxin in patients with chronic heart failure. This has been done prospectively in the Digitalis Investigation Group (DIG) study,³ which in over 6,000 patients with chronic heart failure demonstrated a mortality neutral effect of digoxin. The DIG study monitored patients on digoxin closely and articles 1 and 2 serve to illustrate the importance of this.

We still advocate the use of digoxin in patients with chronic heart failure in sinus rhythm. However, as evidence for the use of beta-adrenoceptor blockade and spironolactone in addition to angiotensin-converting enzyme inhibitors emerges, digoxin naturally falls down the therapeutic hierarchy for patients with chronic heart failure. Despite this, in symptomatic patients on maximal therapy we support the use of digoxin with careful monitoring of renal function and plasma digoxin levels.

The DIG study demonstrated improvements in morbidity which are important to the quality of patients' lives, a very important point in patients with a prognosis worse than some soft tissue tumours.⁴

References

1. Lindsay SJ, Kearney MT, Prescott RJ, Fox KA, Nolan J. Digoxin and mortality in chronic heart failure. UK Heart Investigation. Lancet 1999;354:1003.

2. Spargias KS, Hall AS, Ball SG. Safety concerns about digoxin after acute myocardial infarction. Lancet. 1999; 354:391–2.

3. The Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Eng J Med 1997;336: 525–33.

4. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More "malignant" than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail. 2001;3: 315–22.

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