Dose response characterization of the association of serum digoxin concentration with mortality outcomes in the Digitalis Investigation Group trial

Kirkwood F. Adams*, Javed Butler, J. Herbert Patterson, Wendy Gattis Stough, Jerry L. Bauman, Dirk J. van Veldhuisen, Todd A. Schwartz, Hani Sabbah, John I. Mackowiak, Hector O. Ventura, Jalal K. Ghali

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

30 Citations (Scopus)

Abstract

AimsMany patients with heart failure and reduced EF remain at high risk for hospitalization despite evidence-based therapy. Digoxin may decrease hospitalization; however, uncertainty persists concerning its proper administration and effect on mortality. This study investigated whether using dose response concepts to re-evaluate the relationship between serum digoxin concentration and key mortality outcomes in patients with reduced EF in the Digitalis Investigation Group trial would help clarify efficacy and safety.

Methods and resultsMultivariable Cox proportional hazards modelling and propensity score adjustment assessed the relationship between serum digoxin concentration (0.5ng/mL) as a continuous variable and mortality outcomes. In patients treated with digoxin, a significant linear association was found between serum concentration and all-cause mortality [adjusted hazard ratio (HR) 1.25, 95% confidence interval (CI) 1.14-1.38, P <0.001 per 0.5ng/mL increase in serum concentration]. Based on this relationship, a bidirectional association was found between digoxin therapy and all-cause mortality when compared with placebo. The lowest serum concentrations (0.5-0.7ng/mL) were associated with the lowest risk of all-cause mortality (adjusted HR 0.77, 95% CI 0.67-0.89, P <0.001) while high serum concentrations (1.6-2.0ng/mL) were associated with increased mortality (adjusted HR 1.33, 95% CI 1.12-1.58, P = 0.001). Consistent with this finding, lower serum concentrations (0.5-0.7ng/mL) were associated with reduced death from worsening heart failure and a neutral effect on cardiovascular death not due to worsening heart failure.

ConclusionThese findings favour targeting serum concentrations from 0.5 to 0.7ng/mL when dosing digoxin in patients with heart failure and reduced EF.

Original languageEnglish
Pages (from-to)1072-1081
Number of pages10
JournalEuropean Journal of Heart Failure
Volume18
Issue number8
DOIs
Publication statusPublished - Aug-2016

Keywords

  • Heart failure
  • Drugs
  • Digoxin
  • Morbidity
  • Mortality
  • HEART-FAILURE PATIENTS
  • VENTRICULAR MYOCYTES
  • ATRIAL-FIBRILLATION
  • DIG TRIAL
  • RETROSPECTIVE ANALYSIS
  • TASK-FORCE
  • GLYCOSIDES
  • MANAGEMENT
  • MORBIDITY
  • CALCIUM

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