Validity Importance

Dose response
Enough follow-
Defined goup,
Study Level of

Dechallange-
preceded the
measured in

Consistency
Authors

rechallange
same ways
design evidence

Biological
Exposure
Outcome
Hospitalization

outcome
Mortality

gradient
similar

sense
up
HR = 0.76 HR=0.66
Ahmed A RCT 1b yes yes yes yes yes no yes yes
(0.64-0.9) (0.54-0.79)
not not
Casiglia Cohort 2b yes yes no no no yes RR=1.03
clear clear

Validity

Dose response
Enough follow-
Defined goup,

Study Level of

Dechallange-
preceded the
measured in

Consistency
Authors Importance OR

rechallange
same ways

design evidence

Biological
Exposure
Outcome

outcome

gradient
similar

sense
up

randomized,
Boman double- 2/30 patients deteriorate
2b yes yes yes yes no yes yes yes 5.35
(1983) blind, cross- during placebo period
over
2/14 patients deteriorate
after stopping digoxin
Macarthur 1 patient required
Before-after 4 yes yes yes yes no no yes yes 5.8
(1990) reinstitution of digoxin, 1
patient need larger dose
of diuretic.
2/10 patients deteriorate
after stopping digoxin
Aronow 1 patient required
Before-after 4 yes yes no yes no no yes yes 6.18
(1985) reinstitution of digoxin, 1
patient need larger dose
of diuretic.
Jones 4/13 patients deteriorate
Before-after 4 no yes yes yes no yes yes yes 12.79
(1867) after stopping digoxin

Patients’ expected event rate (PEER) menggambarkan kemungkinan pasien mengalami

perburukan walaupun pasien tetap menggunakan digoxin  50%

𝑃𝐸𝐸𝑅(𝑂𝑅 − 1) + 1
𝑁𝑁𝐻 =
𝑃𝐸𝐸𝑅(𝑂𝑅 − 1)(1 − 𝑃𝐸𝐸𝑅)

0.6(5.35 − 1) + 1
𝑁𝑁𝐻 =
0.6(5.35 − 1)(1 − 0.6)
= 3.5 = 4 orang
 Discontinuation of maintenance digoxin in elderly with chronic heart failure and sinus rhythm:
An Evidence Based Case Report

Della Puspita Sari, Siska Widyawati

Jatirejo Primary Health Care, Mojokerto, East Java

Introduction: Chronic heart failure is the most common disease in elderly that need long term
therapy. Digoxin has been used for more than 200 years for treating arrhythmia and chronic heart
failure. Digoxin reduces hospitalizations due to heart failure (HF) and may also reduce mortality at
low serum digoxin concentrations. Although has inotropic effect, potential for toxicity and/or
adverse reactions is associated with long term use of digoxin since its narrow therapeutic range
especially in elderly. Long term digoxin use is particularly common in the elderly with mild to
moderate CHF with sinus rhythm, including in Jatirejo primary health care (PHC). Examination of
digoxin serum concentration is not available in PHC, therefor those patients were in high risk of
digoxin toxicity. This is an evidence based case report about discontinuation of maintenance digoxin
in elderly with chronic heart failure and sinus rhythm.

Method: Literature searching was conducted based on clinical question on August 1st, 2017 using
Pubmed, Proquest, EBSCO, and Science direct, resulted in 5 useful articles to be critically appraised
using CEBM critical appraisal tools for harm.

Result: From 5 articles appraised, one was randomized control trial and four were before-after
study. There were no deterioration happened when patient using digoxin, only 10 from 67 patients
(15%) had symptom deterioration during discontinuation of digoxin. Discontinuation of digoxin
increase the risk of symptom deterioration in elderly with mild to moderate CHF and sinus rhythm
with OR: 7.24 (1.55-33.81) and number needed to harm (NNH): 4 patients. From all studies,
symptoms deterioration can be relieved by reinstitution of digoxin and diuretic.

Discontinuation of digoxin was applied in elderly patient with mild CHF (NYHA I-II) and sinus rhythm.
Close follow up were done for 1 month, no symptom deterioration was found. Patient prescribed
oral diuretic and ACE-inhibitor for long term therapy.

Conclusion: The narrow therapeutic range and the increased sensitivity to digitalis in elderly mean
that digoxin treatment should be used only on clear indications and careful follow-up of serum
concentration. If contraindications to digoxin withdrawal are missing, discontinuation of digoxin
maintenance therapy should be considered, under careful clinical control. Although digoxin
discontinuation may increases the risk of symptom deterioration in elderly patient with CHF and
sinus rhythm, it can be successfully done with careful follow-up.

Keywords: chronic heart failure, digoxin, elderly, sinus rhythm.