Digoxin Use and Adverse Outcomes in Patients With Atrial Fibrillation

Digoxin has long been used for rate control in atrial fibrillation (AF); its safety remains controversial. We performed a literature search using MEDLINE (source PubMed, January 1, 1966, to July 31, 2015) and EMBASE (January 1, 1980, to July 31, 2015) with no restrictions. Studies that reported relative risk (RR) estimates with 95% confidence intervals (CIs) for the associations of interest were included. Pooled effect estimates were obtained by using random-effects meta-analysis. Twenty-two studies involving 586,594 patients were identified. Patients taking digoxin, as compared with those who took no digoxin, experienced an increased risk of death from any cause (RR: 1.29[95% CI 1.16–1.43]), even after reported adjustment for propensity scores (RR: 1.28[95% CI 1.18–1.39]). The risk of death was increased with patients with or without heart failure (RR: 1.12[95% CI 1.02–1.23] and RR: 1.26[95% CI 1.15–1.29], respectively), and patients taking or not taking beta blockers (RR: 1.17 [95% CI 1.06–1.30] and RR: 1.28 [95% CI 1.08–1.51], respectively). Digoxin use was also associated with increased risk of cardiovascular death (RR: 1.32 [95% CI 1.07–1.64]), arrhythmic death (RR: 1.38 [95% CI 1.07–1.79]), and stroke (RR: 1.20 [95% CI 1.004–1.44]). Digoxin treatment is associated with an absolute risk increase of 19 (95% CI 13–26) additional deaths from any cause per 1000 person-years. Digoxin use is associated with a significant increased risk for death from any cause in patients with AF. This finding suggests a need for reconsideration of present treatment recommendations on use of digoxin in AF.