Real-world patterns of digoxin use and safety in heart failure: insights from a contemporary ambulatory cohort

Introduction

Digoxin use in HF has declined due to safety concerns and limited recent evidence, but the DIGIT-HF trial renewed interest in its role, particularly for patients with persistent symptoms or tachycardia. Updated real-world data on its use and safety are therefore needed.

Purpose

To characterize real-world prescribing patterns, indications, monitoring, and safety outcomes of digoxin in patients with HF.

Methods

We performed a retrospective observational study of ambulatory HF patients treated with digoxin, collecting demographic, clinical, echocardiographic, therapeutic, and follow-up outcome data, including indications for initiation and serum digoxin levels.

Results

A total of 59 patients were included, with a mean age of 69.8 ± 11.6 years, BMI 28.3 ± 8.46 kg/m², and advanced systolic dysfunction (mean LVEF 32.6%). Baseline heart rate averaged 75.7 ± 15.4 bpm, and mean systolic/diastolic blood pressures were 115.9 ± 20.3 and 69.1 ± 12.4 mmHg. Biomarker and renal profiles reflected significant disease burden, with a median NT-proBNP of 2134 pg/mL (IQR 1017–3595), mean creatinine 1.20 ± 0.36 mg/dL, and estimated GFR 57.6 ± 21.0 mL/min/1.73m²; chronic kidney disease was present in 30.5%. Atrial arrhythmias were highly prevalent, with atrial fibrillation in 62.7% of patients, whereas sinus rhythm was uncommon (1.7%). Non-ischemic cardiomyopathy predominated (72.4%), and most patients met criteria for HFrEF (72.9%).

Digoxin was mainly prescribed for atrial arrhythmia–related rate control, accounting for almost 90% of indications: 58.6% (n=34) for presumed tachycardiomyopathy with rapid ventricular response and 31.0% (n=18) for rate control irrespective of LVEF. Only 10.3% (n=6) received digoxin primarily for HFrEF management.

Serum digoxin was measured in 34 patients (52 assays), with only one supratherapeutic level (>2 ng/mL), indicating good safety. Digoxin was discontinued in 7 patients (11.9%), mainly due to lack of perceived benefit (57.1%), with isolated cases related to renal function decline, toxic levels or iatrogenic concerns (each 14.3%). Outcomes after withdrawal were favorable, with only one HF hospitalization recorded.

Conclusions

In this real-world cohort, digoxin was used mainly for atrial arrhythmia rate control and showed a favorable safety profile, with rare toxicity and few adverse events even after discontinuation. These findings support its ongoing role as a targeted rate-control option in selected HF patients.

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