Stopping long-term digoxin in heart failure brought events within weeks; IV nicorandil missed its mark in STEMI

The edition in brief

In the blinded withdrawal phase of the DECISION trial, 587 people with heart failure with reduced or mildly reduced ejection fraction who had taken low-dose digoxin or placebo for a median of 36.5 months were switched to stopping blind. Over the following six weeks, cardiovascular death or worsening heart failure events ran at 42.8 per 100 patient-years after digoxin withdrawal versus 5.9 after placebo withdrawal; there were 14 events versus 2 (rate ratio 7.37, 95% CI 1.56 to 34.88). Heart rate and NT-proBNP rose and systolic blood pressure fell. In the CLEAN trial of 1,503 people with STEMI undergoing primary PCI, intravenous nicorandil did not reduce the 12-month composite (13.1% in both arms; rate ratio 0.869, 0.650 to 1.162); nominal differences in cardiovascular death and target-vessel revascularisation were secondary findings. In HELIOS-B, vutrisiran's effect on the primary outcome pointed the same way with or without baseline tafamidis (rate ratio 0.79 with, 0.67 without; interaction P = 0.55), but estimates were numerically smaller on tafamidis and the trial was not designed to test combination therapy. The pearl covers the checks to make when someone on digoxin is unwell.