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

Journal article
Authors A. Malik
R. Masson
S. Singh
W. C. Wu
M. Packer
B. Pitt
Finn Waagstein
C. J. Morgan
R. M. Allman
G. C. Fonarow
A. Ahmed
Published in Journal of the American College of Cardiology
Volume 74
Issue 5
Pages 617-627
ISSN 0735-1097
Publication year 2019
Published at Institute of Medicine
Pages 617-627
Language en
Links dx.doi.org/10.1016/j.jacc.2019.05.0...
Keywords digoxin discontinuation, heart failure, mortality, readmission, reduced ejection fraction, renin-angiotensin inhibition, propensity score, subgroup analysis, optimize-hf, withdrawal, mortality, kidney, mild, hospitalization, association, Cardiovascular System & Cardiology
Subject categories Cardiac and Cardiovascular Systems

Abstract

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. Published by Elsevier on behalf of the American College of Cardiology Foundation.

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