[Digitalis and Heart Failure].Dtsch Med Wochenschr 2026 Jun; 151(12):633-638.DM
Abstract
The current guidelines of the European Society of Cardiology recommend the use of cardiac glycosides/digitalis in patients with heart failure and sinus rhythm only if the LVEF is ≤40% and if heart failure symptoms persist despite therapy with Betablockers, ACE inhibitors (or angiotensin receptor-neprilysin inhibitors), and mineralocorticoid receptor antagonists, in order to reduce the risk of further hospitalizations. Therapy with cardiac glycosides is not recommended in heart failure with an LVEF >40% and sinus rhythm. In patients with atrial fibrillation, therapy with cardiac glycosides may be used primarily for rate control in heart failure with an LVEF >40%, and in those with an LVEF ≤40% if heart rate control under Betablocker therapy is insufficient or not possible. In the recently published DIGIT-HF study, digitoxin at low serum concentrations reduced all-cause mortality and heart-failure-related hospitalizations in patients with heart failure and reduced ejection fraction, in addition to very good guideline-recommended pharmacological and device therapy. Both patients with sinus rhythm and those with atrial fibrillation benefited. Important new study data from the DECISION study on the use of digoxin in heart failure are expected in 2026. Other studies provide indications of favorable effects of cardiac glycosides on pulmonary arterial pressure values in heart failure and on heart-failure surrogate marker in atrial fibrillation. Digitoxin can be used safely at low serum concentrations in symptomatic heart failure with reduced ejection fraction to improve prognosis and prevent heart-failure hospitalizations. In particular, patients with atrial fibrillation, advanced heart-failure symptoms, low blood pressure, and higher heart rates should be treated with digitoxin, as well as patients in whom the use of currently recommended prognosis-improving pharmacotherapy is limited. Cardiac glycosides are an important and safe therapeutic option for rate control in patients with atrial fibrillation and heart failure. The study data on digoxin expected in 2026 are important for the final assessment of the use of cardiac glycosides in heart failure.
