Monday, December 3, 2012

Fluke or Trend? Digoxin vs Afib Mortality

If you repeat a lie often enough, it becomes the truth.  This quote or paraphrase has been (mis)attributed to Joseph Goebbels.  I mention this because, like many other things that we do in medicine, we do so w/o any proof of benefit.  We do so because that's how we were trained.  If you haven't heard variations of grandma's cooking secret, check it out.  In fact, it's imperative that we question what we do and understand the mechanism & rationale behind what we do.

The traditional pharmacologic treatment of atrial fibrillation just took a hit last week in a randomized trial, Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM), published early online in the European Heart Journal in which the authors concluded that use of digoxin led to an increase risk of all-cause mortality in those patients with atrial fibrillation.  The authors compared 2,153 randomized to digoxin to 1,905 who were not given digoxin at baseline.  Of course, over an average of 3.5yrs follow up, these numbers changed such that at last follow up, only 951 were still on digoxin while 1,241 were still devoid of digoxin.  

Despite that AFFIRM was ostensibly a study designed to look at the effect of rate control vs rhythm control in treating atrial fibrillation, the use of digoxin increased all-cause mortality by a statistically significant 41% compared to those who did not receive digoxin, regardless of whether they received an ACE inhibitor, amiodarone, beta blocker, and/or cardioversion.

Now atrial fibrillation has also been associated with heart failure so an analysis was also performed looking at the effect of digoxin on heart failure mortality.  The authors concluded that use of digoxin in the setting of atrial fibrillation w/o heart failure led to a statistically significant 37% increase in all-cause mortality compared to someone who did not receive digoxin.  In someone w/both atrial fibrillation & heart failure, use of digoxin increased all-cause mortality by 41%.

So what do we do with this information?  Ignore it and sweep it under the proverbial rug?  Or press forward with new studies to (dis)prove these findings.  Is this a fluke or start of a trend?  Fear of the unknown is what holds back progress.  

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