Stopping digoxin after a heart failure exacerbation associated with risk of readmission

Patients with heart failure with reduced ejection fraction who were taking digoxin before hospitalization had higher short-term mortality and long-term readmission risk if the drug was discontinued at discharge.

Stopping preadmission digoxin therapy was associated with worse outcomes among hospitalized older patients with heart failure with reduced ejection fraction (HFrEF) receiving guideline-directed medical therapies, a study found.

Researchers sought to determine the relationship between stopping digoxin and outcomes among hospitalized patients with heart failure and an ejection fraction of 45% or less. They studied 3,499 patients from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry who were on digoxin at admission. Digoxin was discontinued before discharge in 721 patients, and researchers used propensity scores to match 698 of them with patients who continued taking digoxin. Results were published by JACC on July 29.

Four years after discharge, having stopped digoxin was associated with significantly higher risks of heart failure readmission (hazard ratio [HR], 1.21; 95% CI, 1.05 to 1.39; P=0.007), all-cause readmission (HR, 1.16; 95% CI, 1.04 to 1.31; P=0.010), and the combined endpoint of heart failure readmission or all-cause mortality (HR, 1.20; 95% CI, 1.07 to 1.34; P=0.002), but not all-cause mortality alone (HR, 1.09; 95% CI, 0.97 to 1.24; P=0.163). At six months and one year after discharge, stopping digoxin was associated with a significantly higher risk of all four outcomes. At 30 days, stopping digoxin was associated with higher risks of all-cause mortality (HR, 1.80; 95% CI, 1.26 to 2.57; P=0.001) and the combined endpoint (HR, 1.36; 95% CI, 1.09 to 1.71; P=0.007), but not heart failure readmission (HR, 1.19; 95% CI, 0.90 to 1.59; P=0.226) or all-cause readmission (HR, 1.03; 95% CI, 0.84 to 1.26; P=0.778).

The authors wrote, “Considering the recent decline in the use of digoxin, a drug known for its efficacy and effectiveness in reducing the risk of hospitalization, the findings of the current study are important because they suggest that in hospitalized patients with HFrEF receiving contemporary GDMT [guideline-directed medical therapies] including beta-blockers and MRAs [mineralocorticoid receptor antagonists], the discontinuation of digoxin therapy may be associated with worse post-discharge outcomes.”

An editorial noted that the medical community may have prematurely abandoned using digoxin for HFrEF. “If the clinician already believes that clinical outcomes can be improved with digoxin on the basis of previous studies, the current study reinforces that conviction in a relatively large patient cohort and long follow-up, albeit in a retrospective analysis from a nonrandomized prospective registry,” the editorial stated. “If the clinician is less convinced that digoxin is truly efficacious in HFrEF, the take home message is simply that if digoxin has been started and is tolerated, stopping it may cause clinical deterioration; it does not demonstrate that the drug is truly effective in the digoxin-naive HFrEF patient.”