Atrial fibrillation: acute: digoxin slowed the heart rate without cardioversion.

Clinical bottom line (level 1b)

  1. Patients with acute-onset fast AF who were haemodynamically stable who had iv digoxin were not clearly more likely to revert to sinus rhythm than patients on placebo.
  2. Patients on iv digoxin had a lower heart rate than patients on placebo (mean difference 25 beats per min).
  3. Patients were more likely to experience adverse effects on digoxin (NNH = 20 at 16 hours) .
The Digitalis in Acute Atrial Fibrillation (DAAF) Trial Group : European Heart Journal 1997; 18: 649-654
Expires November 2003

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: 13 acute hospitals, Sweden

239 patients (aged range 21 to 89 years; mean 66, 54% male) atrial fibrillation for < 7 days

Excluded if
  • <18 years old
  • ongoing treatment with digitalis or other antiarrhythmics (other than beta-blockers or calcium-channel blockers)
  • sick sinus syndrome, history of 2nd or 3rd degree AV block with artificial pacemaker, WPW syndrome
  • heart rate < 60 or > 170 bpm
  • MI within 4 weeks; ongoing MI
  • haemodynamic instability (requiring iv inotropes or diuretics or indication for intensive care)
  • ongoing unstable angina with K < 3.3 mmol/l or Cr > 300 µ mol/l


    • Control Group: (n = 122, 122 analysed): placebo
    Experimental Group: (n = 117, 117 analysed): digoxin 0.25 mg if < 50 kg otherwise 0.50 mg; at 2 and 6 hours a further 0.25 mg administered if 40 to 75 kg (increased to 0.5 mg if > 75 kg at investigator's discretion)

    100% followed for 16 hours

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    failure to cardiovert 16 hours 66
    (54.1%)    		 57
    (48.7%)    		 10%
    (-15% to 30%)    		 5.38%
    (-7.28% to 18.0%)    		 19
    (NNT = 14 to infinity;
    NNH = 6 to infinity)
    adverse effects 16 hours 0
    (0.00%)    		 6
    (5.13%)    		 %
    (% to %)    		 -5.13%
    (-9.13% to -1.13%)    		 -20
    (-88 to -11)
    additional therapy required for tachycardia 16 hours 6
    (4.92%)    		 1
    (0.85%)    		 83%
    (-42% to 98%)    		 4.06%
    (-0.12% to 8.25%)    		 25
    (NNT = 830 to infinity;
    NNH = 12 to infinity)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    heart rate at 16 hours 116.2
    (25.4)     		91.2
    (20.0)     		-25
    (-31 to -19)

  • A fall in heart rate was noted by two hours in patients given digoxin.

    • Comments

    1. The study is too small to show any effect digoxin might have on cardioversion.

    Citation

    1. The Digitalis in Acute Atrial Fibrillation (DAAF) Trial Group , : Intravenous digoxin in acute atrial fibrillation: results of a randomized, placebo-controlled multicentre trial in 239 patients. European Heart Journal 1997; 18: 649-654
    Search Terms: atrial fibrill* in Cochrane
    Contributor: Chris Ball and Clare Wotton, November 2000
    Reviewer:

    Clinical Question.
    Patient acute AF
    Intervention or Exposure digoxin
    Comparison placebo
    Outcome reversion to sinus rhythm, side effects