Digitalis for treatment of heart failure in patients in sinus rhythm

Publisher Website
Google Scholar
Abstract
Background Digitalis glycosides have been in clinical use in the treatment of heart failure (HF) for more than 200 years. In recent years several trials have been conducted to address concerns about efficacy and toxicity. Objectives To examine the effectiveness of digitalis glycosides in treating HF in patients with normal sinus rhythm. To examine the effect of digitalis in patients taking diuretics and angiotensin converting enzyme inhibitors, patients with varying severity and duration of disease; patients with prior exposure to digitalis versus no prior exposure; and patients with "HF due to systolic dysfunction" versus "HF with preserved ejection fraction." Search methods The searches on the following databases were updated in April 2011: The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, and Dissertation Abstracts. Annual meeting abstracts of the American Heart Association, American College of Cardiology, and European Society of Cardiology were also searched from 1996 to November 2010. In addition, reference lists provided by the pharmaceutical industry (GlaxoSmithKline) were searched. Selection criteria Included were randomized placebo‐controlled trials of 20 or more adult patients of either sex with symptomatic HF who were studied for seven weeks or more. Excluded were trials in which the prevalence of atrial fibrillation was 2% or greater, or in which any arrhythmia that might compromise cardiac function or any potentially reversible cause of HF such as acute ischemic heart disease or myocarditis was present. Data collection and analysis Articles selected from the searches described above were evaluated as a joint effort of the co‐authors. The staff of the Cochrane Heart Group ran searches on the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Main results No new studies were identified in the updated searches. Thirteen studies (7896 participants) are included, and major endpoints of mortality, hospitalization, and clinical status, based respectively upon eight, four and 12 of these selected studies, were recorded and analysed. The data show that there is no evidence of a difference in mortality between treatment and control groups, whereas digitalis therapy is associated with a lower rate of hospitalization and of clinical deterioration. The largest study, in which most patients were taking angiotensin converting enzyme inhibitors, showed a significant rise in “other cardiac” deaths, possibly due to arrhythmias. However collectively these findings were based on studies done before beta‐blockers as well as angiotensin receptor blockers and aldosterone antagonists became widely used to treat HF. Authors' conclusions The literature indicates that digitalis may have a useful role in the treatment of patients with HF who are in normal sinus rhythm. New trials are needed to elucidate the importance of digitalis dosage, and its usefulness in the era of beta‐blockers and other agents shown to be effective in treating HF.