Episode #54: The Comeback of Digoxin? Rethinking Its Role in Modern Heart Failure Care

Has digoxin been pushed aside too soon in modern heart failure care? In this episode of Beatwise The Podcast, I speak with Prof. John Cleland about the evolving evidence for digoxin and other digitalis glycosides in heart failure, and whether these long-established treatments still have a role alongside contemporary guideline-directed medical therapy. We revisit the original DIG trial and explore why digoxin fell out of favour, from concerns around sudden cardiac death and arrhythmias to the arrival of newer heart failure therapies. Prof. Cleland explains how modern treatments including beta blockers, MRAs, ARNi, SGLT2 inhibitors and device therapy may change the risk-benefit equation. We also discuss the important differences between digoxin and digitoxin, how digitalis glycosides work, and new evidence that is prompting clinicians to take another look at this old class of drugs.  So where might digoxin fit into heart failure management today? Prof. Cleland shares his perspective on its potential role as an additional therapy for patients with HFrEF who remain symptomatic despite guideline-directed treatment, as well as its use in congestion and atrial fibrillation. We also explore the evidence in patients with HFpEF and AF, including findings from RATE-AF, and what the DECISION trial adds to the debate. Finally, we discuss practical considerations around digoxin dosing and monitoring - and why Prof. Cleland believes the question of digoxin’s role in modern heart failure care still deserves a definitive large-scale clinical trial. **Key issues addressed:** - Why digoxin fell out of favour in heart failure care - Digoxin vs digitoxin: what is the difference? - How digitalis glycosides work in heart failure - What the original DIG trial actually showed - How modern heart failure therapy may change the safety of digoxin - The role of digoxin in HFrEF despite guideline-directed medical therapy - Digoxin for atrial fibrillation and heart-rate control - What RATE-AF tells us about digoxin vs beta blockers in HFpEF and AF - Whether digoxin has a role in managing congestion - The latest evidence from DECISION and contemporary digitalis trials - Digoxin dosing, therapeutic levels and monitoring - Why we may need a large, pragmatic digoxin trial **EPISODE HIGHLIGHTS:** 00:00 The Comeback of Digoxin? 00:50 Introducing Prof. John Cleland 01:33 Digoxin vs Digitoxin: What’s the Difference? 02:27 How Digitalis Glycosides Work 03:13 What Did the DIG Trial Show? 04:50 Why Did Digoxin Fall Out of Favour? 06:55 Has Modern Heart Failure Therapy Changed the Risk? 07:39 Who Should Receive Digoxin Today? 08:34 Digoxin in HFrEF and Sinus Rhythm 10:39 Digoxin and Atrial Fibrillation 11:37 HFpEF, AF and the RATE-AF Trial 13:24 Can Digoxin Help with Congestion? 16:22 The DECISION Trial and Current Guidelines 17:24 Low Blood Pressure and Advanced Heart Failure 19:11 Digoxin Dosing and Monitoring 20:57 Does Digoxin Need a New Mega-Trial? 23:43 Final Thoughts If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content. Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community! * * * Hosted on Acast. See acast.com/privacy for more information.