Is Foxglove Effective in Heart Failure?

Abstract

SUMMARYBackground: Digoxin is the oldest known treatment for heart failure (HF) and has been demonstrated to reduce admissions for worsening heart failure in a large randomized trial recruiting patients in sinus rhythm with heart failure and ejection fraction <45%. This study forms the basis for current international guidelines recommending that digoxin should be considered in patients with symptomatic HF despite optimal doses of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, b-blockers, and mineralocorticoid receptor antagonists in addition to device therapy, if indicated. However, digoxin predates mortality reducing HF therapies, and this article reviews the historical and recent data. Methods: Multiple PubMed searches were performed including, but not limited to, the search terms "digoxin," "heart failure," "efficacy," "treatment," "side-effects," "morbidity," "mortality," and "arrythmia." Articles were excluded if not relevant, not in English or without abstract. Reference lists of relevant articles were manually searched for further references. Due to the large number of articles retrieved, a selection was reviewed based on the authors' best judgement. Results: Three randomized controlled trials and three large contemporary observational reports of digoxin therapy in heart failure and sinus rhythm were retrieved. Other studies were noted that included patients with heart failure and atrial fibrillation, which were also reviewed. Conclusion: Definitive randomized evidence of digoxin efficacy as add-on therapy in HF is lacking because most landmark trials of modern HF disease modifying agents postdate the randomized studies of digoxin. Furthermore, questions remain regarding the optimum dose of digoxin and there are signals that digoxin may be harmful in some patients with HF. All contemporary data for digoxin in HF are derived from observational studies and the findings are conflicting. Despite two centuries of experience using cardiac glycosides to treat HF, fundamental questions regarding the efficacy and safety of digoxin in HF remain unanswered.

Peripartum Cardiomyopathy

“…Digoxin can be safely used during pregnancy, but its role in the treatment of systolic heart failure is currently being debated. 48,49 Studies of new experimental therapies have thus far been equivocal or negative. A small 1999 nonrandomized study of 6 patients given intravenous immunoglobulin showed improvement compared with 11 historical control subjects, 50 but no further studies have been conducted.…”

Digoxin Toxicity Caused by an Interaction with the Novel Hepatitis C Medication Ledipasvir/Sofosbuvir

“…The net effect of digoxin therapy is 1) lengthening of the cardiac action potential causing slower heart rates, and 2) increasing intracellular calcium concentration leading to increased myocardial contractility. 12,[14][15][16] Digoxin also has autonomic effects, including inhibition of sympathetic nervous outflow and enhanced parasympathetic tone. Through its autonomic effects, digoxin decreases automaticity, prolongs the effective refractory period, and slows conduction velocity through the atrioventricular (AV) node.…”

Peripartum Cardiomyopathy: The Hidden Enemy

“…to avoid promoting uterine activity, β-1-selective agents can be preferable. Digoxin may be safely used during pregnancy, but its role is currently being debated [55,56].…”