Digoxin use in patients with AF and adverse cardiovascular outcomes: a retrospective analysis of the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in AF.

In 14,171 patients, digoxin (DG) was used at baseline in 5239 (37%). DG was linked to significant increase in all-cause mortality, vascular death, and sudden death in patients with AF. A randomised trial of DG in treatment of AF patients with and without heart failure is needed.

According to a commentary, apart from reigniting an age-old controversy, no plausible reason or empirical evidence exists to discontinue digoxin in the treatment of AF. The commentators note that use of digoxin has clearly been shown to be safe in the DIG trial of almost 7000 patients with sinus rhythm and heart failure when dosing was based on a simple clinical formula, and there is little reason to suspect that its safety profile should be different in patients with AF with and without heart failure when serum level is maintained at <1.0 ng/mL. They suggest that the available data point to a need to redefine how digoxin is used in patients with AF, and recommend that it should continue to be used in such patients, but dosing should be adjusted with a goal of maintaining a serum level with an upper limit of 1.0 ng/mL and not to target ventricular rate.