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ACE INHIBITORS DON'T ELIMINATE THE NEED FOR DIGOXIN.

It became clear in the 1980s that patients with congestive heart failure in normal sinus rhythm did worse if they stopped digitalis and took diuretics only. Now that angiotensin-converting-enzyme inhibitors are established in treating CHF, the question becomes: do patients on ACE inhibitors still need digitalis? A new study argues forcefully that they do.

The authors randomized 178 stable patients with mild-to- moderate CHF who were taking ACE inhibitors, diuretics, and digoxin to receive the first two agents plus either continued digoxin or placebo for 12 weeks. All patients were in normal sinus rhythm and had ejection fractions of 35 percent or less.

The placebo group more often developed worsening heart failure requiring study withdrawal (23 vs. 4 patients). Maximal exercise tolerance and submaximal exercise endurance remained stable with continued digoxin but decreased with placebo. The placebo group also had greater declines in New York Heart Association class, ejection fraction, and quality-of-life scores and greater increases in heart rate and body weight. Four MIs or sudden deaths occurred with digoxin versus none with placebo, a nonsignificant difference. There was one case of digitalis toxicity.

Comment: This study demonstrates convincing short-term benefits from continued use of digitalis. However, the four MIs and sudden deaths raise the question of whether digitalis has some risks. A massive long-term study now under way should settle this question.

— ALK

Published in Journal Watch General Medicine July 6, 1993

Citation(s):

Smith TW. Digoxin in heart failure. N Engl J Med 1993 Jul 1 329 51-53.

• Original article (Subscription may be required)
• Medline abstract (Free)

Packer M et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. N Engl J Med 1993 Jul 1 329 1-7.

• Original article (Subscription may be required)
• Medline abstract (Free)