Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data

ObjeCtive To clarify the impact of digoxin on death and clinical outcomes across all observational and randomised controlled trials, accounting for study designs and methods. Comprehensive literature search of Medline, Embase, the Cochrane Library, reference lists, and ongoing studies according to a prospectively registered design (PROSPERO: CRD42014010783), including all studies published from 1960 to July 2014 that examined treatment with digoxin compared with control (placebo or no treatment). Unadjusted and adjusted data pooled according to study design, analysis method, and risk of bias.

[1]  S. Hohnloser,et al.  Digoxin-associated mortality: a systematic review and meta-analysis of the literature. , 2015, European heart journal.

[2]  P. Okin,et al.  Digoxin use and risk of mortality in hypertensive patients with atrial fibrillation , 2015, Journal of hypertension.

[3]  G. Fonarow,et al.  Digoxin Use and Subsequent Outcomes Among Patients in a Contemporary Atrial Fibrillation Cohort. , 2015, Journal of the American College of Cardiology.

[4]  Abdur Rahman Khan,et al.  Digoxin in patients with atrial fibrillation and heart failure: A meta-analysis. , 2015, International journal of cardiology.

[5]  A. Farcomeni,et al.  Digoxin treatment is associated with increased total and cardiovascular mortality in anticoagulated patients with atrial fibrillation. , 2015, International journal of cardiology.

[6]  T. N. Harrison,et al.  Digoxin and Risk of Death in Adults With Atrial Fibrillation: The ATRIA-CVRN Study , 2013, Circulation. Arrhythmia and electrophysiology.

[7]  M. Ezekowitz,et al.  2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. , 2014, Circulation.

[8]  P. Gao,et al.  Interaction Between Digoxin and Dronedarone in the PALLAS Trial , 2014, Circulation. Arrhythmia and electrophysiology.

[9]  L. Rasmussen,et al.  Pre-existing atrial fibrillation and risk of arterial thromboembolism and death following pneumonia: a population-based cohort study , 2014, BMJ Open.

[10]  J. González-Juanatey,et al.  Outcomes of a contemporary sample of patients with atrial fibrillation taking digoxin: results from the AFBAR study. , 2014, Revista espanola de cardiologia.

[11]  T. Chao,et al.  Does digoxin increase the risk of ischemic stroke and mortality in atrial fibrillation? A nationwide population-based cohort study. , 2014, The Canadian journal of cardiology.

[12]  I. V. Van Gelder,et al.  Digoxin in patients with permanent atrial fibrillation: data from the RACE II study. , 2014, Heart rhythm.

[13]  M. Turakhia,et al.  Increased mortality associated with digoxin in contemporary patients with atrial fibrillation: findings from the TREAT-AF study. , 2014, Journal of the American College of Cardiology.

[14]  H. Behlouli,et al.  Relation of digoxin use in atrial fibrillation and the risk of all-cause mortality in patients ≥65 years of age with versus without heart failure. , 2014, The American journal of cardiology.

[15]  K. Bennett,et al.  A cohort study of digoxin exposure and mortality in men with prostate cancer , 2014, BJU international.

[16]  Z. Goldberger,et al.  Digitalis use in contemporary clinical practice: refitting the foxglove. , 2014, JAMA internal medicine.

[17]  J. Fleg,et al.  Digoxin and 30-day all-cause hospital admission in older patients with chronic diastolic heart failure. , 2014, The American journal of medicine.

[18]  J. Fleg,et al.  Digoxin use and lower 30-day all-cause readmission for Medicare beneficiaries hospitalized for heart failure. , 2014, The American journal of medicine.

[19]  M. Almendro-Delia,et al.  The previous use of digoxin does not worsen early outcome of acute coronary syndromes: an analysis of the ARIAM Registry , 2014, Internal and Emergency Medicine.

[20]  Nileshkumar J Patel,et al.  Digoxin significantly improves all-cause mortality in atrial fibrillation patients with severely reduced left ventricular systolic function. , 2013, International journal of cardiology.

[21]  Alanna M. Chamberlain,et al.  Temporal Relationship and Prognostic Significance of Atrial Fibrillation in Heart Failure Patients With Preserved Ejection Fraction A Community-Based Study , 2013 .

[22]  A. Go,et al.  Effectiveness and Safety of Digoxin Among Contemporary Adults With Incident Systolic Heart Failure , 2013, Circulation. Cardiovascular quality and outcomes.

[23]  R. Charnigo,et al.  Increased mortality among patients taking digoxin--analysis from the AFFIRM study. , 2013, European heart journal.

[24]  S. Murphy When 'digoxin use' is not the same as 'digoxin use': lessons from the AFFIRM trial. , 2013, European heart journal.

[25]  J. Cleland,et al.  Lack of evidence of increased mortality among patients with atrial fibrillation taking digoxin: findings from post hoc propensity-matched analysis of the AFFIRM trial. , 2013, European heart journal.

[26]  S. Sheen,et al.  Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. , 2013, Journal of clinical epidemiology.

[27]  L. Providência,et al.  Digoxin in advanced heart failure patients: a question of rhythm. , 2013, Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology.

[28]  D. Altman,et al.  Individual patient data meta-analysis of beta-blockers in heart failure: rationale and design , 2013, Systematic Reviews.

[29]  Biykem Bozkurt,et al.  2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. , 2013, Circulation.

[30]  Habib Gamra,et al.  Distribution and Risk Profile of Paroxysmal, Persistent, and Permanent Atrial Fibrillation in Routine Clinical Practice: Insight From the Real-Life Global Survey Evaluating Patients With Atrial Fibrillation International Registry , 2012, Circulation. Arrhythmia and electrophysiology.

[31]  B. Strom,et al.  Observational cohort study of the safety of digoxin use in women with heart failure , 2012, BMJ Open.

[32]  L. A. Bonet,et al.  ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 , 2012, Turk Kardiyoloji Dernegi arsivi : Turk Kardiyoloji Derneginin yayin organidir.

[33]  R. Corzo,et al.  Mortality and morbidity of heart failure treated with digoxin. A propensity‐matched study , 2011, International journal of clinical practice.

[34]  P. Austin An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies , 2011, Multivariate behavioral research.

[35]  J. McMurray,et al.  Eplerenone in patients with systolic heart failure and mild symptoms. , 2011, The New England journal of medicine.

[36]  G. Fonarow,et al.  Epidemiology and risk profile of heart failure , 2011, Nature Reviews Cardiology.

[37]  Jeroen J. Bax,et al.  Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). , 2010, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[38]  R. Hakim,et al.  Digoxin associates with mortality in ESRD. , 2010, Journal of the American Society of Nephrology : JASN.

[39]  J. Cohn,et al.  Digoxin use and heart failure outcomes: results from the Valsartan Heart Failure Trial (Val-HeFT). , 2010, Congestive heart failure.

[40]  M. Cheitlin Comparison of Beta Blocker and Digoxin Alone and in Combination for Management of Patients With Atrial Fibrillation and Heart Failure , 2010 .

[41]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. , 2010, International journal of surgery.

[42]  M. Rosenqvist,et al.  Digoxin in atrial fibrillation: report from the Stockholm Cohort study of Atrial Fibrillation (SCAF) , 2009, Heart.

[43]  M. Mamas,et al.  A meta‐analysis of the prognostic significance of atrial fibrillation in chronic heart failure , 2009, European journal of heart failure.

[44]  J. Butler,et al.  Digoxin Therapy Does Not Improve Outcomes in Patients With Advanced Heart Failure on Contemporary Medical Therapy , 2009, Circulation. Heart failure.

[45]  C. Schneider,et al.  ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: application of natriuretic peptides. , 2008, European heart journal.

[46]  M. White,et al.  Digoxin and reduction of heart failure hospitalization in chronic systolic and diastolic heart failure. , 2008, The American journal of cardiology.

[47]  J. Higgins,et al.  Meta-Regression in Stata , 2008 .

[48]  B. Bozkurt,et al.  Digoxin and clinical outcomes in systolic heart failure patients on contemporary background heart failure therapy. , 2008, The American journal of cardiology.

[49]  Per Enblad,et al.  International Subarachnoid Aneurysm Trial of Neurosurgical Clipping Versus Endovascular Coiling: Subgroup Analysis of 278 Elderly Patients , 2008, Stroke.

[50]  D. Altman,et al.  Assessing Risk of Bias in Included Studies , 2008 .

[51]  S. Hennessy,et al.  Declining Public Health Burden of Digoxin Toxicity From 1991 to 2004 , 2008, Clinical pharmacology and therapeutics.

[52]  E. Braunwald,et al.  Effects of digoxin at low serum concentrations on mortality and hospitalization in heart failure: a propensity-matched study of the DIG trial. , 2008, International journal of cardiology.

[53]  Ian Shrier,et al.  Should meta-analyses of interventions include observational studies in addition to randomized controlled trials? A critical examination of underlying principles. , 2007, American journal of epidemiology.

[54]  H. Melhus,et al.  Digoxin and mortality in atrial fibrillation: a prospective cohort study , 2007, European Journal of Clinical Pharmacology.

[55]  S. Olsson,et al.  Digitalis: a dangerous drug in atrial fibrillation? An analysis of the SPORTIF III and V data , 2007, Heart.

[56]  Ali Ahmed,et al.  Digoxin and reduction in mortality and hospitalization in geriatric heart failure: importance of low doses and low serum concentrations. , 2007, The journals of gerontology. Series A, Biological sciences and medical sciences.

[57]  Ali Ahmed,et al.  Effects of Digoxin on Morbidity and Mortality in Diastolic Heart Failure: The Ancillary Digitalis Investigation Group Trial , 2006, Circulation.

[58]  J. Fleg,et al.  Serum digoxin concentration and outcomes in women with heart failure: A bi‐directional effect and a possible effect modification by ejection fraction , 2006, European journal of heart failure.

[59]  Eric L Eisenstein,et al.  What is the economic value of digoxin therapy in congestive heart failure patients? Results from the DIG trial. , 2006, Journal of cardiac failure.

[60]  P. Hauptman,et al.  Digoxin use and digoxin toxicity in the post-DIG trial era. , 2006, Journal of cardiac failure.

[61]  M. Rich,et al.  Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial. , 2006, European heart journal.

[62]  Christopher H Schmid,et al.  In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias. , 2005, Journal of clinical epidemiology.

[63]  J. Fleg,et al.  The effect of gender on outcome in digitalis-treated heart failure patients. , 2005, Journal of cardiac failure.

[64]  C. O'connor,et al.  Relationship of serum digoxin concentration to mortality and morbidity in women in the digitalis investigation group trial: a retrospective analysis. , 2004, Journal of the American College of Cardiology.

[65]  T. Therneau,et al.  The mortality risk associated with digitalis treatment after myocardial infarction , 1987, Cardiovascular Drugs and Therapy.

[66]  S. Gottlieb,et al.  Consistency of the beneficial effect of metoprolol succinate extended release across a wide range dose of angiotensin-converting enzyme inhibitors and digitalis. , 2004, Journal of cardiac failure.

[67]  D. Levy,et al.  Lifetime Risk for Development of Atrial Fibrillation: The Framingham Heart Study , 2004, Circulation.

[68]  Julian P T Higgins,et al.  Controlling the risk of spurious findings from meta‐regression , 2004, Statistics in medicine.

[69]  G. Guyatt,et al.  Digitalis for treatment of congestive heart failure in patients in sinus rhythm: a systematic review and meta-analysis. , 2004, Journal of cardiac failure.

[70]  M. Hernán A definition of causal effect for epidemiological research , 2004, Journal of Epidemiology and Community Health.

[71]  J. McMurray,et al.  Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK , 2004, Heart.

[72]  D. Rubin Using Propensity Scores to Help Design Observational Studies: Application to the Tobacco Litigation , 2001, Health Services and Outcomes Research Methodology.

[73]  U. Goldbourt,et al.  Digoxin and mortality in survivors of acute myocardial infarction: Observations in patients at low and intermediate risk , 1995, Cardiovascular Drugs and Therapy.

[74]  W. Maisel,et al.  Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. , 2003, The American journal of cardiology.

[75]  Harlan M Krumholz,et al.  Association of serum digoxin concentration and outcomes in patients with heart failure. , 2003, JAMA.

[76]  A. Molyneux International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial , 2002, The Lancet.

[77]  Eric J. Eichhorn,et al.  Effect of concomitant digoxin and carvedilol therapy on mortality and morbidity in patients with chronic heart failure. , 2000, The American journal of cardiology.

[78]  Salim Yusuf,et al.  Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients , 2000, The Lancet.

[79]  M. Kearney,et al.  Digoxin and mortality in chronic heart failure. UK Heart Investigation. , 1999, The Lancet.

[80]  B. Pitt,et al.  The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. , 1999, The New England journal of medicine.

[81]  U. Goldbourt,et al.  Are coronary patients at higher risk with digoxin therapy? An ongoing controversy. , 1999, International journal of cardiology.

[82]  J. Pearl,et al.  Causal diagrams for epidemiologic research. , 1999, Epidemiology.

[83]  J. Zhang,et al.  What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. , 1998, JAMA.

[84]  V. Tikhonoff,et al.  Should digoxin be proscribed in elderly subjects in sinus rhythm free from heart failure? A population-based study. , 1998, Japanese heart journal.

[85]  K. Dickstein,et al.  [Calcium channel blockers in heart failure]. , 1997, Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke.

[86]  E. J. Brown,et al.  The effect of digoxin on mortality and morbidity in patients with heart failure. , 1997, The New England journal of medicine.

[87]  R. Campbell,et al.  Digoxin therapy and survival in heart failure in sinus rhythm. , 1997, International journal of cardiology.

[88]  M. Gheorghiade,et al.  Economic outcomes of withdrawal of digoxin therapy in adult patients with stable congestive heart failure. , 1995, Journal of the American College of Cardiology.

[89]  L. Køber,et al.  Is digoxin an independent risk factor for long-term mortality after acute myocardial infarction? , 1994, European heart journal.

[90]  J. Brouwer,et al.  Double-blind placebo-controlled study of ibopamine and digoxin in patients with mild to moderate heart failure: results of the Dutch Ibopamine Multicenter Trial (DIMT). , 1993, Journal of the American College of Cardiology.

[91]  P. Mølstad,et al.  Digitoxin-associated mortality in acute myocardial infarction. , 1991, European heart journal.

[92]  S. Nattel,et al.  Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The Adverse Experience Committee; and the Multicenter Diltiazem Postinfarction Research Group. , 1991, Circulation.

[93]  R. Mayou,et al.  Exercise capacity and quality of life in the treatment of heart failure , 1990, Clinical pharmacology and therapeutics.

[94]  R. Schlant,et al.  A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. , 1989, The New England journal of medicine.

[95]  M. Wilén,et al.  Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. The Captopril-Digoxin Multicenter Research Group. , 1988, JAMA.

[96]  Double-blind placebo-controlled comparison of digoxin and xamoterol in chronic heart failure. The German and Austrian Xamoterol Study Group. , 1988, The Lancet.

[97]  N. Laird,et al.  Meta-analysis in clinical trials. , 1986, Controlled clinical trials.

[98]  A. Jaffe,et al.  Digoxin therapy and mortality after myocardial infarction. Experience in the MILIS Study. , 1986, The New England journal of medicine.

[99]  R. Byington,et al.  Association of digitalis therapy with mortality in survivors of acute myocardial infarction: observations in the Beta-Blocker Heart Attack Trial. , 1985, Journal of the American College of Cardiology.

[100]  J. Fleiss,et al.  Effect of digitalis treatment on survival after acute myocardial infarction. , 1985, The American journal of cardiology.

[101]  E. Gilpin,et al.  Prognostic importance of digitalis after acute myocardial infarction. , 1984, Journal of the American College of Cardiology.

[102]  K. Bailey,et al.  The Effects of Digitalis on Survival in High‐risk Patients with Coronary Artery Disease: The Coronary Artery Surgery Study (CASS) , 1983, Circulation.

[103]  D. Rubin,et al.  The central role of the propensity score in observational studies for causal effects , 1983 .

[104]  A. Moss,et al.  Digitalis‐associated Cardiac Mortality After Myocardial Infarction , 1981, Circulation.

[105]  W. Haenszel,et al.  Statistical aspects of the analysis of data from retrospective studies of disease. , 1959, Journal of the National Cancer Institute.

[106]  ReviewTM Digoxin use in patients with atrial fibrillation and adverse cardiovascular outcomes , 2022 .