Mortality in heart failure with atrial fibrillation: Role of digoxin and diuretics (original) (raw)
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Kardiologia Polska
Background: Digoxin is used in the treatment of atrial fibrillation (AF) and heart failure (HF). It was reported to increase the risk of death in HF. Studies on digoxin are based mainly on patients treated some years ago, before the era of common b-blocker use. Aim: This study aims to show the influence of digoxin in a modern cohort of HF patients on top of the contemporary guideline-directed treatment. Methods: This study retrospectively analyses the Polish part of the European Society of Cardiology Heart Failure Long-Term Registry. It includes 912 patients treated for HF between February 2012 and January 2013, and followed until May 2014. At baseline, 19.1% took digoxin, 89.6% angiotensin convertase enzyme inhibitors or angiotensin receptor blockers, 91.9% b-blockers, and 69.4% mineralocorticoid receptor antagonists. Results: Digoxin is associated with increased risk of death after adjustment for significant covariates in patients who have HF with reduced ejection fraction (HFrEF) but no AF history (hazard ratio [HR] 2.52, 95% confidence interval [CI] 1.23-5.19; p = 0.011), and it does not influence significantly the risk of hospitalisation (adjusted HR 1.46, 95% CI 1.05-1.72; p = 0.11). Digoxin use shows no significant association with the risk of death or hospitalisation in patients with AF and HFrEF or HF with preserved ejection fraction (HFpEF). Patients on digoxin present a significantly worse clinical status with lower left ventricular ejection fraction and higher New York Heart Association class, and fewer of them received the guideline-directed treatment. Conclusions: Digoxin is associated with increased risk of death in HFrEF patients without AF history receiving the guideline-directed treatment. Digoxin seems to be employed in patients with worse clinical status, which may at least partially explain its association with increased risk of death.
Digoxin and mortality in atrial fibrillation: a prospective cohort study
European Journal of Clinical Pharmacology, 2007
Objective The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study showed that rhythm-control treatment of patients with atrial fibrillation (AF) offered no survival advantage over a rate-control strategy. In a subgroup analysis of that study, it was found that digoxin increased the death rate [relative risk (RR)= 1.42), but it was suggested that this may have been attributable to prescription of digoxin for patients at greater risk of death, such as those with congestive heart failure (CHF). No study has investigated a priori the effect of digoxin on mortality in patients with AF. This study aimed to address this question. Methods Using data from the Registry of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), we studied the 1-year mortality among patients admitted to coronary care units with AF, CHF, or AF+CHF with or without digoxin (n=60,764) during 1995-2003. Adjustment for differences in background characteristics and other medications and treatments was made by propensity scoring. Results Twenty percent of patients with AF without CHF in this cohort were discharged with digoxin. This group had a higher mortality rate than the corresponding group not given digoxin [adjusted RR 1.42 (95% CI 1.29-1.56)], whereas no such difference was seen among patients with CHF with or without AF, although these patients had a nearly three-times higher mortality. Conclusion The results suggest that long-term therapy with digoxin is an independent risk factor for death in patients with AF without CHF.
Journal of the American Heart Association, 2017
Digoxin is widely used in patients with atrial fibrillation despite the lack of randomized controlled trials. Observational studies report conflicting results regarding its association with mortality, perhaps because of residual confounding by the presence of heart failure (HF). In the ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) trial, clinical outcomes of patients with atrial fibrillation with and without HF were examined by baseline digoxin use during a median follow-up of 2.8 years. HF was defined at baseline as prior or current clinical stage C or D HF. Of 21 105 patients enrolled, 6327 (30%) were treated with digoxin at baseline. Among patients without HF (n=8981), digoxin use (20%) was independently associated with sudden cardiac death (adjusted hazard ratio, 1.51; 95% CI, 1.10-2.08), with no significant interaction by age, sex, left ventricular ejection fraction, renal function, o...
The American Journal of Cardiology, 2009
In patients with atrial fibrillation (AF) and heart failure (HF),  blockers and digoxin reduce the ventricular rate, but controversy exists concerning how these drugs affect prognosis in this setting. This study compared the effects of  blocker and digoxin on mortality in patients with both AF and HF. In a single-center institution, patients with AF and HF seen . Of 1,269 consecutive patients with both AF and HF, 260 were treated with a  blocker alone, 189 with  blocker plus digoxin, 402 with digoxin alone, and 418 without  blocker or digoxin (control group). During a follow-up of 881 ؎ 859 days, 247 patients died. Compared with the control group, treatment with  blocker was associated with a decreased mortality (relative risk ؍ 0.58, 95% confidence interval 0.40 to 0.85, p ؍ 0.005 for  blocker alone and 0.59, 95% confidence interval 0.40 to 0.87, p ؍ 0.008 for  blocker plus digoxin). By contrast, treatment with digoxin alone was not associated with a better survival (relative risk ؍ 0.97, 95% confidence interval 0.73 to 1.30, p ؍ NS). Results remained significant after adjustment for potential confounders and similar when we considered, separately, HF with permanent or nonpermanent AF, presence or absence of coronary disease, and patients with decreased or preserved systolic function. In conclusion, in unselected patients with AF and HF, treatments with  blocker alone or with  blocker plus digoxin are associated with a similar decrease in the risk of death. Digoxin alone is associated with a worse survival chance, similar to that of patients without any rate control treatment.
Effect of cardiovascular drugs on mortality in atrial fibrillation and chronic heart failure
Scand. Cardiovasc. J., 2014
Objectives. To study mortality rates among men and women with atrial fibrillation (AF) and concomitant chronic heart failure (CHF) prescribed different classes of cardiovascular drugs in primary health care. Design. A cohort of men (n 1159) and women (n 1155) aged 45 years or above and diagnosed with both AF and CHF from patient records from 75 primary care centers in Sweden were included in the study. regression models with mortality as the outcome were used, with adjustment for a propensity score comprising age, cardiovascular co-morbidities, education, marital status, and pharmacotherapy. We analysed using Cox regression with hazard ratio (Hr), and laplace regression with years until 10% of the patients had died, with 95% confidence intervals (95% CI). Independent variables were prescribed cardiovascular drugs. Results. Individuals prescribed anticoagulants versus no treatment gained 1.95 years (95% CI 0.47-3.43), anticoagulants versus antiplatelets 1.26 years (95% CI 0.42-2.10), calcium channel blockers 1.17 years (95% CI 0.21-2.14), and statins 1.49 years (95% CI 0.39-2.59). Among patients 80 years or above no significant effect by anticoagulants was seen, Hr 0.73 (95% CI 0.43-1.23). Conclusions. our findings suggest that life may be prolonged in patients with AF and concomitant CHF in primary care prescribed anticoagulants, calcium channel blockers, and statins.
Prognosis of heart failure treated with digoxin or with ivabradine: A cohort study in the community
International journal of clinical practice, 2018
Resting heart rate (HR) reduction with ivabradine (IVA) improves outcomes of patients with heart failure and reduced ejection fraction (HFrEF). Nevertheless, the best option to slow HR in patients with HFrEF treated with beta-blockers and a HR >70 bpm is unsettled. To evaluate whether, in patients with HFrEF, commencing therapy with digoxin (CT-DIG) is associated to a worse prognosis than commencing treatment with ivabradine (CT-IVA). Observational study over 10 years on 2364 patients with HFrEF in sinus rhythm and a HR >70 bpm. Main outcomes were mortality, hospitalisations and visits. We analyse the independent relationship of CT-DIG or CT-IVA with the prognosis, stratifying patients for cardiovascular comorbidity, and for other potential confounders (378 patients who CT-DIG vs another 355 patients who CT-IVA vs another 1631 patients non-exposed to IVA or DIG). During a median follow-up of 57.5 months, 1751 patients (74.1%) died, and 2151 (91.0%) were hospitalised for HF. CT...