We recommend digoxin in patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy to relieve symptoms and reduce hospitalizations. (Recommendation Strong, Quality Moderate).

We recommend digoxin in patients with chronic AF and poor control of ventricular rate despite optimal beta-blocker therapy, or when beta-blocker cannot be used (Recommendation Strong, Quality Low).

Values and Preferences These recommendations place a high value on the understanding that the use of cardiac glycosides in chronic HF remains controversial. Digoxin can cause atrial and ventricular arrhythmias particularly in the presence of hypokalemia. Not all glycosides and not all preparations have been studied in terms of efficacy and safety.