Stopping long-term digoxin in heart failure was followed by more admissions

Design

Prespecified analysis of blinded withdrawal in a randomised placebo-controlled trial

Population

587 patients with HFrEF or HFmrEF after a median 36.5 months of digoxin or placebo

Primary outcome

Cardiovascular death or worsening heart failure events after withdrawal

Effect

42.8 vs 5.9 events per 100 patient-years; 14 vs 2 events, RR 7.37 (95% CI 1.56–34.88)

DECISION randomised 1,001 people with heart failure to low-dose digoxin or placebo for a median of 36.5 months. At the end, 587 still on study drug underwent a blinded withdrawal and were seen again at six weeks, with all events adjudicated.

Before withdrawal, event rates were similar (5.7 vs 6.5 per 100 patient-years). After withdrawal, cardiovascular death or worsening heart failure rose to 42.8 per 100 patient-years in those coming off digoxin against 5.9 in those coming off placebo. That was 14 events, 12 of them hospitalisations, against two (RR 7.37, 95% CI 1.56–34.88). Heart rate and NT-proBNP rose, and systolic pressure fell, after digoxin was stopped.

Digoxin is often stopped quietly at a medication review or on admission, on the assumption that it adds little to modern therapy. This analysis suggests that, for people stable on it, removal can unmask deterioration within weeks. The event count is small, which is why the interval is wide, but the direction and the physiological changes are consistent. This is a secondary analysis and guidelines have not changed.

• Think twice before stopping long-term digoxin in a stable patient with reduced or mildly reduced ejection fraction.
• If digoxin must be stopped, review heart rate, symptoms and weight within a few weeks.
• Record why digoxin was started so the reason is not lost at a later medication review.
• Consider checking NT-proBNP after withdrawal where symptoms or heart rate change.

Why it matters

It challenges the assumption that digoxin is a passenger that can be dropped at any medication review.

Don't overread it

This was a withdrawal analysis of a modest trial; it does not show digoxin should be started more often.

The statistics, in plain English

A rate ratio of 7.37 sounds dramatic, but it rests on 14 events against 2, so the 95% interval runs from about 1.6 to 35. The direction is clear; the size is uncertain.

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