Skip to main content
SpringerLink
Log in

When, and When Not, to Use Digoxin in the Elderly

  • Review Article
  • Drug Therapy
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Summary

Digitalis has been widely used in the treatment of cardiac disease for more than 200 years. The present article reviews the current role of digitalis in the management of heart failure and atrial fibrillation (AF) in light of recent study findings.

Generally, first-line therapy for the management of heart failure due to systolic dysfunction should include an ACE inhibitor and a diuretic. In patients who remain symptomatic despite the use of these drugs, the addition of digoxin should be considered. Because digoxin has been shown to reduce the number of hospital admissions attributable to worsening heart failure, more liberal use of digoxin in the management of heart failure may be justified.

Digoxin may be adequate as monotherapy for ventricular rate control in patients with chronic AF, particularly in sedentary and elderly patients. A β-blocker or calcium antagonist (either alone or in combination with digoxin) is indicated when digoxin is ineffective for ventricular rate control. Digoxin is ineffective in restoring sinus rhythm, preventing paroxysms or controlling rate in paroxysmal AF.

The elderly are at an increased risk of digoxin toxicity. Low dosages of digoxin appear to be effective in the treatment of heart failure due to systolic dysfunction and may reduce the incidence of digitalis toxicity in these patients. In elderly patients with AF and inadequate rate control who are receiving digitalis monotherapy, adding another atrioventricular nodal blocking drug may be more appropriate than increasing the digoxin dose, in order to avoid toxic digoxin levels.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Packer M. The neurohumoral hypothesis: a theory to explain the mechanism of disease progression in heart failure. J Am Coll Cardiol 1992; 20: 248–54

    Article  PubMed  CAS  Google Scholar 

  2. Francis GS, Cohn JN, Johnson G, et al., for the V-HeFT VA Cooperative Studies Group. Plasma norepinephrine, plasma renin activity, and congestive heart failure: relations to survival and the effects of therapy in V-HeFT II. Circulation 1993; 87 Suppl. VI: 40–8

    Google Scholar 

  3. Katz AM. Potential deleterious effects of inotropic agents in the therapy of chronic heart failure. Circulation 1986; 73 Suppl. III: 184–8

    Google Scholar 

  4. van Veldhuisen DJ, de Graeff PA, Remme WJ, et al. Value of digoxin in heart failure and sinus rhythm: new features of an old drug? J Am Coll Cardiol 1996; 28: 813–9

    Article  PubMed  Google Scholar 

  5. Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA 1988; 259: 539–44

    Article  Google Scholar 

  6. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med 1989; 320: 677–83

    Article  Google Scholar 

  7. Gheorghiade M, Ferguson D. Digoxin: a neurohumoral modulator in heart failure? Circulation 1989; 84: 2181–6

    Article  Google Scholar 

  8. Watanabe AM. Digitalis and the autonomic nervous system. J Am Coll Cardiol 1985; 5 Suppl. A: 35A-42A

    Article  Google Scholar 

  9. Ferguson DW. Digitalis and neurohormonal abnormalities in heart failure and implications for therapy. Am J Cardiol 1992; 69(18): 24G-33G

    Article  Google Scholar 

  10. Gheorghiade M, Hall V, Lakier JB, et al. Comparative hemodynamic and neurohormonal effects of intravenous captopril and digoxin and their combinations in patients with severe heart failure. J Am Coll Cardiol 1989; 13: 134–42

    Article  PubMed  CAS  Google Scholar 

  11. van Veldhuisen DJ, Man in’t Veld AJ, Dunselman PHJM, et al. Double-blind, placebo-controlled study of ibopamine and digoxin in patients with mild to moderate heart failure: results of the Dutch Ibopamine Multicenter Trial (DIMT). J Am Coll Cardiol 1993; 22: 1564–73

    Article  PubMed  Google Scholar 

  12. Ferguson DW, Berg WJ, Sanders JS, et al. Sympathoinhibitory responses to digitalis glycosides in heart failure patients: direct evidence from sympathetic neural recordings. Circulation 1989; 80: 65–77

    Article  PubMed  CAS  Google Scholar 

  13. Krum H, Bigger JT, Goldsmith RL, et al. Effect of long term digoxin therapy on autonomic function in patients with chronic heart failure. J Am Coll Cardiol 1995; 25: 289–94

    Article  PubMed  CAS  Google Scholar 

  14. Brouwer J, van Veldhuisen DJ, Man in’t Veld AJ, et al. Heart rate variability in patients with mild to moderate heart failure: effects of neurohumoral modulation by digoxin and ibopamine. J Am Coll Cardiol 1995; 26: 983–90

    Article  PubMed  CAS  Google Scholar 

  15. German and Austrian Xamoterol Study Group. Double-blind, placebo-controlled comparison of digoxin and xamoterol in chronic heart failure. Lancet 1988; 1 I: 489–93

    Google Scholar 

  16. Packer M, Gheorghiade M, Young JB, et al. for the RADIANCE Study. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. N Engl J Med 1993; 329: 1–7

    Article  PubMed  CAS  Google Scholar 

  17. Uretsky BF, Young JB, Shahidi FE, et al., on behalf of the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol 1993; 22: 955–62

    Article  PubMed  CAS  Google Scholar 

  18. De Bono D. Digoxin in eurhythmic heart failure: PROVED or ‘not proven’? [editorial] Lancet 1994; 343: 128–9

    Article  PubMed  Google Scholar 

  19. Jaeschke R, Oxman AD, Guyatt GH. To what extent do congestive heart failure patients in sinus rhythm benefit from digoxin therapy? A systematic overview and meta-analysis. Am J Med 1990; 88: 279–86

    Article  PubMed  CAS  Google Scholar 

  20. van Veldhuisen DJ, Brouwer J, Man in’t Veld AJ, et al. Progression of mild untreated heart failure during 6 months follow-up and clinical and neurohumoral effects of ibopamine and digoxin as monotherapy. Am J Cardiol 1995; 75: 796–800

    Article  PubMed  Google Scholar 

  21. Just H, Drexler H, Taylor SH, et al., for the CADS Study Group. Captopril versus digoxin in patients with coronary artery disease and mild heart failure: a prospective, double-blind, placebo-controlled multicenter study. Herz 1993; 18 Suppl. 1: 436–43

    PubMed  Google Scholar 

  22. Moss AJ, Davis HT, Conard DL, et al. Digitalis-associated cardiac mortality after myocardial infarction. Circulation 1981; 64: 1150–6

    Article  PubMed  CAS  Google Scholar 

  23. Smith TW. Digitalis: mechanisms of action and clinical use. N Engl J Med 1988; 318: 358–65

    Article  PubMed  CAS  Google Scholar 

  24. Gheorghiade M, Hall VB, Jacobson G, et al. Effects of increasing maintenance dose digoxin on left ventricular function and neurohormones in patients with chronic heart failure treated with diuretics and angiotensin-converting enzyme inhibitors. Circulation 1995; 92: 1801–7

    Article  PubMed  CAS  Google Scholar 

  25. Lewis RP. Clinical use of serum digoxin concentrations. Am J Cardiol 1992; 69(18): 97G-106G

    Article  Google Scholar 

  26. The Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997; 336: 525–33

    Article  Google Scholar 

  27. Kannel WB, Abbott RD, Savage DD, et al. Epidemiologie features of atrial fibrillation: the Framingham study. N Engl J Med 1982; 306: 1018–22

    Article  PubMed  CAS  Google Scholar 

  28. Gosselink ATM, Crijns HJGM, van den Berg MP, et al. Functional capacity before and after cardioversion of atrial fibrillation: a controlled study. Br Heart J 1994; 72: 161–6

    Article  PubMed  CAS  Google Scholar 

  29. Gosselink ATM, Smit AJ, Crijns HJGM, et al. Alteration of peripheral vasodilatory reserve capacity after cardioversion of atrial fibrillation. Eur Heart J 1996; 17: 926–34

    Article  PubMed  CAS  Google Scholar 

  30. Gosselink ATM, Crijns HJGM, Hamer HPM, et al. Changes in left and right atrial size after cardioversion of atrial fibrillation: role of mitral valve disease. J Am Coll Cardiol 1993; 22: 1666–72

    Article  PubMed  CAS  Google Scholar 

  31. Sopher SM, Camm AJ. Atrial fibrillation: maintenance of sinus rhythm versus rate control. Am J Cardiol 1996; 77(3): 24A-37A

    Article  Google Scholar 

  32. Lewis R, Lakhani TA, McDevitt DG. A comparison of verapamil and digoxin in the treatment of atrial fibrillation. Eur Heart J 1987; 8: 148–53

    PubMed  CAS  Google Scholar 

  33. David D, Di Segni E, Klein HO, et al. Inefficacy of digitalis in the control of heart rate in patients with chronic atrial fibrillation: beneficial effect of an added beta blocking agent. Am J Cardiol 1979; 44: 1378–82

    Article  PubMed  CAS  Google Scholar 

  34. Lang R, Klein HD, Weiss E, et al. Superiority of oral verapamil therapy to digoxin in treatment of chronic atrial fibrillation. Chest 1983; 83: 491–9

    Article  PubMed  CAS  Google Scholar 

  35. Roth A, Harrison E, Mitani G, et al. Efficacy and safety of medium and high-dose diltiazem alone and in combination with digoxin for control of heart rate at rest and during exercise in patients with chronic atrial fibrillation. Circulation 1986; 73: 316–24

    Article  PubMed  CAS  Google Scholar 

  36. Ahuja RC, Sinha N, Saran RK, et al. Digoxin or verapamil or metoprolol for heart rate control in patients with mitral stenosis: a randomized, cross-over study. Int J Cardiol 1989; 25: 325–32

    Article  PubMed  CAS  Google Scholar 

  37. Koh KK, Kwon KS, Park HB, et al. Efficacy and safety of digoxin alone and in combination with low-dose diltiazem or betaxolol to control ventricular rate in chronic atrial fibrillation. Am J Cardiol 1995; 75: 88–90

    Article  PubMed  CAS  Google Scholar 

  38. van den Berg MP, Crijns HJGM, Gosselink ATM, et al. Chronotropic response to exercise in patients with atrial fibrillation: relation to functional state. Br Heart J 1993; 70: 150–3

    Article  PubMed  Google Scholar 

  39. DiBianco R, Morganroth J, Freitag JA, et al. Effects of nadolol on the spontaneous and exercise-provoked heart rate of patients with chronic atrial fibrillation receiving stable dosages of digoxin. Am Heart J 1984; 108: 1121–7

    Article  Google Scholar 

  40. Zarowitz BJ, Gheorghiade M. Optimal heart rate control for patients with chronic atrial fibrillation: are pharmacologic choices truly changing? Am Heart J 1992; 123: 1401–3

    Article  PubMed  CAS  Google Scholar 

  41. Lundstrom T, Ryden L. Ventricular rate control and exercise performance in chronic atrial fibrillation. J Am Coll Cardiol 1990; 16: 86–90

    Article  PubMed  CAS  Google Scholar 

  42. Falk RH, Knowlton AA, Bernard SA, et al. Digoxin for converting recent-onset atrial fibrillation to sinus rhythm: a randomized, double-blinded trial. Ann Intern Med 1987; 106: 503–6

    PubMed  CAS  Google Scholar 

  43. Moe GK, Han J. Digitalis and the autonomic nervous system. In: Fisch C, Surawicz B, editors. Digitalis. New York: Grune & Stratton, 1969: 110–7

    Google Scholar 

  44. Rawles JM, Metcalfe MJ, Jennings K. Time of occurrence, duration, and ventricular rate of paroxysmal atrial fibrillation: the effect of digoxin. Br Heart J 1990; 63: 225–7

    Article  PubMed  CAS  Google Scholar 

  45. Gulan E, Flugelman MY, Glickson M, et al. Failure of long-term digitalization to prevent rapid ventricular response in patients with paroxysmal atrial fibrillation. Chest 1991; 99: 1038–40

    Article  Google Scholar 

  46. Falk RH, Leavitt JI. Digoxin for atrial fibrillation: a drug whose time has gone? Ann Intern Med 1991; 114: 573–5

    PubMed  CAS  Google Scholar 

  47. Braunwald E, Klocke FJ. Digitalis. Annu Rev Med 1965; 16: 371–86

    Article  PubMed  CAS  Google Scholar 

  48. Sellers TD, Bashore TM, Gallagher JJ. Digitalis in the pre-excitation syndrome-analysis during atrial fibrillation. Circulation 1977; 56: 260–6

    Article  PubMed  Google Scholar 

  49. Aronow WS. Digoxin or angiotensin converting enzyme inhibitors for congestive heart failure in geriatric patients: which is the preferred treatment? Drugs Aging 1991; 1: 98–103

    Article  PubMed  CAS  Google Scholar 

  50. Ware JA, Snow E, Luchi JM, et al. Effect of digoxin on ejection fraction in elderly patients with congestive heart failure. J Am Geriatr Soc 1984; 32: 631–5

    PubMed  CAS  Google Scholar 

  51. Cody RJ. Characteristics of the elderly patient with congestive heart failure. Am J Geriatr Cardiol 1992; 1: 30–41

    Google Scholar 

  52. Wong WF, Gold S, Fukuyama O, et al. Diastolic dysfunction in elderly patients with congestive heart failure. Am J Cardiol 1989; 63: 1526–8

    Article  PubMed  CAS  Google Scholar 

  53. Lakatta EG. Changes in the cardiovascular function with aging. Eur Heart J 1990; 11 Suppl. C: 22–9

    PubMed  Google Scholar 

  54. Marcus F. Pharmacokinetic interactions between digoxin and other drugs. J Am Coll Cardiol 1985; 5 (5 Suppl. A): 82A–90A

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology/Thoraxcenter, University Hospital Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands

    A. T. Marcel Gosselink, Dirk J. van Veldhuisen & Harry J. G. M. Crijns

Authors
  1. A. T. Marcel Gosselink
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dirk J. van Veldhuisen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Harry J. G. M. Crijns
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gosselink, A.T.M., van Veldhuisen, D.J. & Crijns, H.J.G.M. When, and When Not, to Use Digoxin in the Elderly. Drugs & Aging 10, 411–420 (1997). https://doi.org/10.2165/00002512-199710060-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-199710060-00002

Keywords

Search

Navigation