Editing Digoxin (section)

=== Irregular heartbeat ===
The most common indications for digoxin are [[atrial fibrillation]] and [[atrial flutter]] with rapid [[ventricle (heart)|ventricular]] response,<ref>{{cite journal | vauthors = Sticherling C, Oral H, Horrocks J, Chough SP, Baker RL, Kim MH, Wasmer K, Pelosi F, Knight BP, Michaud GF, Strickberger SA, Morady F | display-authors = 6 | title = Effects of digoxin on acute, atrial fibrillation-induced changes in atrial refractoriness | journal = Circulation | volume = 102 | issue = 20 | pages = 2503–8 | date = November 2000 | pmid = 11076824 | doi = 10.1161/01.CIR.102.20.2503 | s2cid = 127927 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Hallberg P, Lindbäck J, Lindahl B, Stenestrand U, Melhus H | title = Digoxin and mortality in atrial fibrillation: a prospective cohort study | journal = European Journal of Clinical Pharmacology | volume = 63 | issue = 10 | pages = 959–71 | date = October 2007 | pmid = 17684738 | doi = 10.1007/s00228-007-0346-9 | s2cid = 30951337 }}</ref> especially in older or less active patients,<ref>{{cite book |title=Kumar and clark's clinical medicine |date=2017 |publisher=Elsevier |location=Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto |isbn=9780702066009 |page=972 |edition=9th}}</ref> though [[beta blocker]]s and/or [[calcium channel blocker]]s may be preferred in some patients, such as younger more active ones, or those without heart failure or hemodynamic instability.<ref name=Craig2019>{{cite journal | vauthors = January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW | display-authors = 6 | title = 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons | journal = Circulation | volume = 140 | issue = 2 | pages = e125–e151 | date = July 2019 | pmid = 30686041 | doi = 10.1161/CIR.0000000000000665 | s2cid = 59304609 | doi-access = free }}</ref>

Early observational studies showed an increased risk of death in patients taking digoxin, despite an attempt to allow for other risk factors for death (so-called [[propensity score matching]]).<ref>{{cite journal | vauthors = Ouyang AJ, LvYN, Zhong HL, Wen JH, Wei XH, Peng HW, Zhou J, Liu LL | display-authors = 6 | title = Meta-analysis of digoxin use and risk of mortality in patients with atrial fibrillation | language = English | journal = The American Journal of Cardiology | volume = 115 | issue = 7 | pages = 901–906 | date = April 2015 | pmid = 25660972 | doi = 10.1016/j.amjcard.2015.01.013 | doi-access = free }}</ref><ref name=Vamos2015>{{cite journal | vauthors = Vamos M, Erath JW, Hohnloser SH | title = Digoxin-associated mortality: a systematic review and meta-analysis of the literature | journal = European Heart Journal | volume = 36 | issue = 28 | pages = 1831–1838 | date = July 2015 | pmid = 25939649 | doi = 10.1093/eurheartj/ehv143 | doi-access = free }}</ref> However, systematic reviews focusing on [[randomised controlled trial|randomised controlled trials]] of digoxin (which ensured similarity between patients on digoxin, and those not on it) showed no difference in mortality.<ref>{{cite journal | vauthors = Sethi NJ, Nielsen EE, Safi S, Feinberg J, Gluud C, Jakobsen JC | title = Digoxin for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and trial sequential analysis of randomised clinical trials | journal = PLOS ONE | volume = 13 | issue = 3 | pages = e0193924 | date = 2018-03-08 | pmid = 29518134 | pmc = 5843263 | doi = 10.1371/journal.pone.0193924 | bibcode = 2018PLoSO..1393924S | doi-access = free }}</ref><ref>{{cite journal | vauthors = Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GY, Steeds RP, Townend J, Kotecha D | display-authors = 6 | title = Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data | journal = BMJ | volume = 351 | pages = h4451 | date = August 2015 | pmid = 26321114 | pmc = 4553205 | doi = 10.1136/bmj.h4451 }}</ref> Evidence suggested the increased mortality in patients taking digoxin was due to their having worse heart disease than those not taking it.<ref name="Ziff_2015">{{cite journal | vauthors = Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GY, Steeds RP, Townend J, Kotecha D | display-authors = 6 | title = Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data | journal = BMJ | volume = 351 | issue =  | pages = h4451 | date = August 2015 | pmid = 26321114 | pmc = 4553205 | doi = 10.1136/bmj.h4451 }}</ref> Cardiac arrhythmias may also occur when patients are prescribed digoxin alongside [[Thiazide|thiazides]] and [[Loop diuretic|loop diuretics]].<ref name="Kumar & Clark">{{cite book |title=Kumar and Clark's clinical medicine |date=2017 |publisher=Elsevier |location=Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto |isbn=9780702066009 |page=24 |edition=9th}}</ref>