It is now known that only medications that blunt and modulate neurohormonal tone such angiotensin-converting 
enzyme [ACE] inhibitors, beta-adrenergic blockers, and aldosterone antagonists improve long-term survival in patients with heart failure according to an article of American Family Physician Journals in August 2006.
Before an emerging theory which explain the mechanisms of heart failure, digoxin was recommended to improve cardiac output routinely. Prospective clinical trials are needed to determine the serum digoxin concentration that is associated with the most clinical benefit and to determine the role of digoxin therapy for women. Digoxin generally does not have a role in the treatment of diastolic heart failure and is not a first-line therapy for managing atrial fibrillation in patients with heart failure, according to the article.
Spencer A. Morris, Pharm.D., B.C.P.S from Georgetown Hospital System, Georgetown, South Carolina and his colleagues performed Reanalysis of Digoxin Therapy for Heart Failure with previous DIG trial have brought into question to the safety of digoxin, the optimal serum digoxin concentration for treating heart failure and the role of the patient’s sex in digoxin therapy.
To initiate digoxin therapy, they used the American College of Cardiology (ACC)/American Heart Association (AHA) or ACC/AHA staging system for heart failure with corresponding to NYHA functional classifications (tabel provided). In this article, we can also find detailed information about serum digoxin concentration in flow chart looked, initiating digoxin therapy in women, digoxin role in the treatment of symptomatic diastolic dysfunction, and digoxin potential use for heart failure and concomitant atrial fibrillation.
For patients with atrial fibrillation, the AAFP/ACP guidelines recommend the following drugs as first-line therapy for controlling heart rate during exercise and while at rest: atenolol (Tenormin), metoprolol (Toprol XL), diltiazem (Cardizem), and verapamil (Calan). Digoxin has only been shown to effectively control heart rate at rest and, therefore, should only be used as a second-line therapy for heart rate control in patients with atrial fibrillation.
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