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Digoxin in HFrEF — EECC MCQ

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ModerateHeart FailureDigoxin in HFrEFEECC

A 70-year-old woman with HFrEF (LVEF 30%) and sinus rhythm is on bisoprolol 10 mg, sacubitril/valsartan 97/103 mg bd, eplerenone 50 mg, and dapagliflozin 10 mg. She has AF-free and is euvolaemic. Her resting HR is 75 bpm. She is started on digoxin 62.5 micrograms daily. What is the primary expected benefit of digoxin in this context?

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Correct answer: B — Reduction in HF hospitalisations without a mortality benefit

The DIG trial established that digoxin in HFrEF patients in sinus rhythm reduces HF hospitalisations (by ~28%) but has no effect on all-cause mortality. The ESC HF Guidelines include digoxin as a Class IIb recommendation for symptomatic HFrEF patients in sinus rhythm already on optimal GDMT. The mechanism is positive inotropy (Na⁺/K⁺-ATPase inhibition) and neurohormonal modulation (vagotonic effect). Digoxin has a narrow therapeutic index; serum levels should be maintained at 0.5-0.9 ng/mL (higher levels associated with increased mortality). It does not significantly improve LVEF or prevent AF.

Reference: ESC (2023): Focused Update on Heart Failure; DIG Trial