Digoxin for atrial fibrillation: a drug whose time has gone?

For over 200 years digitalis compounds have been used to treat atrial fibrillation. The rapid ventricular response to atrial fibrillation is frequently treated with digoxin to produce a controlled heart rate. Digoxin has also been proposed as a treatment for terminating recent-onset atrial fibrillation, for maintaining sinus rhythm after an episode of atrial fibrillation, and as prophylactic therapy in patients with paroxysmal atrial fibrillation to prevent excessive tachycardia during a paroxysm. Perhaps because it has been used for so long, few of these indications have been studied scientifically until recently. Studies now suggest that in patients with atrial fibrillation, digoxin is a poor drug for controlling heart rate during exertion, has little or no effect in terminating the arrhythmia, and may occasionally aggravate paroxysmal atrial fibrillation. Despite adequate digitalization, the heart rate at the onset of a paroxysm of fibrillation in patients receiving the drug does not differ from the heart rate in patients not receiving it. This article discusses the current role of digoxin in the management of patients with chronic, recent-onset, or paroxysmal atrial fibrillation.