Stopping digoxin leads to poor discharge outcomes for hospitalized patients with heart failure

Awais Malik, Ravi Masson, Steven Singh, Wen-Chih Wu, Milton Packer, Bertram Pitt, Finn Waagstein, Charity J Morgan, Richard M Allman, Gregg C Fonarow, Ali Ahmed

Overview

This study showed in a nationwide sample of hospitalized heart failure patients that stopping digoxin leads to increased risk of death at 30 days and increased risk of needing to be rehospitalized for heart failure.

Summary

The use of digoxin has been decreasing despite being a low-cost and effective medication for reducing the need for heart failure hospitalizations, the leading cause for hospital care in older adults. This study adds information to suggest that even with the availability of newer medications, digoxin remains an important treatment for patients with heart failure.

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Author Comments

4616750 Richard M Allman, MD
4616750 Richard M Allman, MD
George Washington University
Clinical Professor of Medicine
Washington, DC | United States
It is an honor to work with this multi-institutional team of investigators led by Dr. Ali Ahmed, an international expert on the care of older adults with heart failure. 4616750 Richard M Allman, MD

Digoxin Discontinuation and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction.

Authors:
4616750 Richard M Allman, MD
4616750 Richard M Allman, MD
George Washington University
Clinical Professor of Medicine
Washington, DC | United States

J Am Coll Cardiol 2019 08;74(5):617-627

Veterans Affairs Medical Center, Washington, DC; Georgetown University, Washington, DC; George Washington University, Washington, DC. Electronic address:

Background: The deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme inhibitors are well-documented.

Objectives: The authors sought to determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline-directed medical therapies including beta-blockers and mineralocorticoid receptor antagonists.

Methods: Of the 11,900 hospitalized patients with HFrEF (EF ≤45%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, a matched cohort of 698 pairs of patients, balanced on 50 baseline characteristics (mean age 76 years; mean EF 28%; 41% women; 13% African American; 65% on beta-blockers) was assembled.

Results: Four-year post-discharge, digoxin discontinuation was associated with significantly higher risks of HF readmission (hazard ratio [HR]: 1.21; 95% confidence interval [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 HF readmission or all-cause mortality (HR: 1.20; 95% CI: 1.07 to 1.34; p = 0.002), but not all-cause mortality (HR: 1.09; 95% CI: 0.97 to 1.24; p = 0.163). Discontinuation of digoxin was associated with a significantly higher risk of all 4 outcomes at 6 months and 1 year post-discharge. At 30 days, digoxin discontinuation 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 of HF 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).

Conclusions: Among hospitalized older patients with HFrEF on more contemporary guideline-directed medical therapies, discontinuation of pre-admission digoxin therapy was associated with poor outcomes.

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Source
http://dx.doi.org/10.1016/j.jacc.2019.05.064DOI Listing
August 2019
5 Reads
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