Revisiting AF with Heart Failure: Time To Let Go Digoxin

After 2 years advocating digoxin over amiodarone in acute management of AF for patient with heart failure, I think its time to change our practice. The believe in digoxin was partly build on knowledge I gather in Shirley Ooi (I was cheated).

But digoxin is really a slow drug (slug). Its like recommend a slow car, slow phone or slow laptop to your friend. Your friend get agitated and you don’t know what to say. Hahaha. Its good. You revisit your knowledge and you found something new.

What I learned:


1. Digoxin is slow drug. Medscape say 5-30 min onset. But literature say it can be up to 6 hours. We don’t have that 6 hours. But before it get 6 hours, primary team get agitated and boom, amiodarone started.

2. Digoxin is not a first line drug. Not for monotherapy.

Beta blocker

1. Beta blocker can be use in heart failure. Damn you Shirley Ooi.

2. Eventhough prognosis benefit that beta blocker show in heart failure with sinus rhythm are not shown in heart failure with AF, its still useful due to benefit that the patient get from rate control.

3. Metoprolol is the go drug for me since available in IV and oral. Of course we need to fight for IV preparation in our ED.

Magnesium Sulphate

1. As an adjunct drug if 1st and 2nd line drug fail. Regardless the magnesium level.


1. Still the bad boy. Pulmonary, hepatic and thyroid toxicity.

2. High succesful rate to convert to sinus rhythm. Dangerous if AF >48 H and patient not well anticoagulate.

3. Do consider when all above failed, develop hypotension or contraindicated (e.g. cant use beta blocker; asthma)

4. DON’T use amiodarone in AF >48 h or unknown duration without anticoagulation.


1. Calculate and anticoagulate accordingly if needed.


1. Short and sweet

2. Guideline for nerd

3. Podcast if you like

4. Role of digoxin in acute setting

5. Role of magnesium sulphate in AF

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