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Inappropriate Use of Digoxin in Older Hospitalized Heart Failure Patients

^a Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine,
^b Department of Epidemiology and International Health, School of Public Health, and
^c Center for Aging, University of Alabama at Birmingham
^d Section of Geriatrics, Education, and Clinical Center, Birmingham VA Medical Center, Alabama
^e Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Alabama
^f Alabama Quality Assurance Foundation, Birmingham

Ali Ahmed, Division of Geriatric Medicine, University of Alabama at Birmingham, 1530 3rd Ave South, CH-19, Ste-219, Birmingham, AL 35294-2041 E-mail: aahmed{at}uab.edu.

Background. Older adults are more likely to suffer from the adverse effects of digoxin. Studies have described the inappropriate use of digoxin in various populations. The objective of this study was to determine the correlates of inappropriate digoxin use in older heart failure patients.

Methods. We studied older hospitalized heart failure patients with documented left ventricular (LV) function evaluation and electrocardiography. Digoxin use was considered inappropriate if patients had preserved LV systolic function (ejection fraction 40%) or if they had no atrial fibrillation (AF). We compared baseline patient characteristics by indication for digoxin and tested statistical significance using Pearson's chi-square analysis and Student's t tests. Using logistic regression, we determined the correlates of inappropriate use and initiation of digoxin.

Results. Subjects (N = 603) had a mean age of 79 (±7) years; 59% were women, and 18% were African American. A total of 376 patients (62%) were discharged on digoxin, and 223 (37%) had no indication for its use. Half of the patients without an indication for digoxin received the drug. Of 132 patients without an indication and not already on digoxin, 38 (29%) were initiated on it. After adjustment for various patient and care characteristics, prior digoxin use (adjusted odds ratio [OR] 11.47, 95% confidence interval [CI] 5.72–23.02) and pulse 100/min (adjusted OR 2.33, 95% CI 1.10–4.94) were associated with inappropriate digoxin use. Pulse 100/min was also associated with inappropriate initiation of the drug (adjusted OR 2.95, 95% CI 1.28–6.78).

Conclusions. Inappropriate use of digoxin was common and was associated with prior use. Tachycardia was associated with inappropriate use and initiation. Electrocardiography and echocardiography should be performed in all older heart failure patients. Digoxin therapy should not be initiated or continued in patients without any evidence of LV systolic dysfunction or chronic AF.