Stopping digoxin in heart failure is not a neutral act

The edition in brief

In the DECISION trial, 587 people with heart failure and reduced or mildly reduced ejection fraction who had taken low-dose digoxin or placebo for a median of three years underwent blinded withdrawal. Cardiovascular death or worsening heart failure rose sharply in those coming off digoxin (42.8 vs 5.9 events per 100 patient-years; 14 events vs 2, RR 7.37), with heart rate and NT-proBNP rising and blood pressure falling. ICare-FASTER, a stepped-wedge cluster-randomised trial of almost 60,000 emergency presentations with possible acute coronary syndrome, found point-of-care high-sensitivity troponin I shortened the stay by 13%, about 47 minutes, with no change in 30-day myocardial infarction or cardiac death (0.39% in both arms). In HELIOS-B, the effect of vutrisiran on death and cardiovascular events in ATTR cardiomyopathy pointed the same way with or without background tafamidis (rate ratio 0.79 vs 0.67, no significant interaction), though estimates were smaller on tafamidis. The Enlighten registry of 787 extravascular ICD attempts reported 89% freedom from major complications at a year, appropriate therapy in 7.3% and inappropriate shocks in 7.1%, mostly from non-cardiac oversensing.