Chronic heart failure and digoxin withdrawal - Tips from Other Journals

Date: Feb 1, 1994

Patients with chronic heart failure often receive angiotensin-converting enzyme (ACE) inhibitors in addition to diuretics and digoxin. Since the ACE inhibitors expert hemodynamic and clinical benefits similar or superior to those achieved with digoxin, some investigators have concluded that digoxin may not be necessary. This has prompted some physicians to withdraw digoxin therapy from patients. Packer and colleagues examined the effect of withdrawing digoxin from patients who are clinically stable while receiving digoxin, diuretics and an ACE inhibitor.

A total of 178 patients were studied. Patients were eligible for the study if they had heart failure, left ventricular ejection fraction of 35 percent or less and normal sinus rhythm. Ninety-three patients were randomly assigned to receive placebo instead of digoxin during the 12-week study period, and 85 patients were randomly assigned to continue receiving digoxin.

In the placebo group, 23 patients experienced worsening heart failure that required therapeutic intervention. Of these patients, 12 required emergency care or hospitalization. In the digoxin group, four patients had worsening heart failure, including two who required emergency care or hospitalization. The relative risk of worsening heart failure in the placebo group, compared with the digoxin group, was 5.9.

Patients in the placebo group had a decrease in treadmill exercise tolerance. On self-evaluation, 31 percent of patients receiving placebo reported that they felt worse or much worse, compared with 9 percent of those continuing to receive digoxin.

The authors conclude that digoxin withdrawal is associated with clinical deterioration in a specific cohort of patients with chronic heart failure and impaired systolic function who have normal sinus rhythm, even when ACE inhibitors are being taken concurrently.

In an accompanying editorial, Smith cautions against making too many conclusions at this time on the basis of these results, given the clinical trial's relatively small study sample and its short-term observation period. Smith also notes that a large, multicenter trial evaluating the effect of digoxin on the survival of such patients will not be complete until mid-1995. (New England Journal of Medicine, July 1, 1993, vol. 329, pp. 1, 51.)

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