In HF therapy, what is the role of digoxin?

• A. Digoxin is the first-line mortality-reducing therapy in HFrEF.
• B. Digoxin is added for symptom relief in HFrEF with atrial fibrillation or persistent symptoms; does not improve survival.
• C. Digoxin should never be used in heart failure.
• D. Digoxin replaces beta-blockers in therapy.

Answer: (B)

Digoxin in heart failure is used mainly for symptom relief and rate control, not to extend survival. The best choice reflects this: it’s added when a patient with HFrEF has atrial fibrillation or persistent symptoms despite optimized therapy, with no proven mortality benefit.

Evidence from the classic trial shows that digoxin can reduce HF hospitalizations and improve symptoms, particularly in those with AF, but it does not improve overall survival when patients are already on guideline-directed therapy. Because of its narrow therapeutic window and potential for toxicity, it’s used as an adjunct rather than a primary life-prolonging therapy.

In practice, it complements beta-blockers, ACE inhibitors/ARBs or ARNI, MRAs, and SGLT2 inhibitors rather than replacing them. Start at a low dose, monitor kidney function and electrolytes, be mindful of drug–drug interactions, and watch for signs of toxicity such as GI symptoms, confusion, vision changes, or arrhythmias.