This Commentary article in JAMA discusses how the use of digoxin in the treatment of patients with chronic heart failure has decreased considerably, and argues that it is time to ‘remember a forgotten drug’. 

Digoxin was licensed for this use based on the results of the Digitalis Investigation Group trial, which found that it reduced hospitalisations when added to standard therapy (diuretics and ACE inhibitors), although there was no effect on survival. 
Available data suggest that digoxin use has decreased considerably in the last 10 years; the author postulates several factors responsible for this, including lack of promotion by the pharmaceutical industry, its displacement by other therapies for heart failure (e.g. beta-blockers, ACE inhibitors, aldosterone-blocking agents), and the generation of safety concerns by retrospective studies of the Digitalis Investigation Group trial.

The author notes that registries have shown high mortality and heart-failure related rehospitalisation rates within 90 days of discharge despite receipt of evidence-based therapies.  They discuss the ideal properties that an agent for the treatment of heart failure should have, and how digoxin has many of these.  They also acknowledge the remaining questions; including the fact that digoxin has not been well studied in acute heart failure syndromes (previous studies were conducted before the routine use of beta-blockers), and that it has a narrow therapeutic range.  

The author concludes that “the net clinical benefit of digoxin in acute heart failure syndromes should be re-evaluated, given the unacceptably high post-discharge hospitalisation rates and subsequent increasing economic costs, despite standard therapies including ACE inhibitors and β-blockers. This is particularly important given the negative results in terms of efficacy, safety, or both with newer therapies that include both vasodilators and inotropic agents.”