급성 심부전에서 디곡신의 사용은 주로 심방세동 환자에서만 고려합니다. 알고리즘에서도 나와있지만 심방세동이 없는 성인 심부전 환자에서의 디곡신의 사용은 권고된 바가 없습니다.

2022 심부전 가이드라인 p259에는 다음과 같이 설명되어있습니다.

 
[Uptodate : Secondary pharmacologic therapy for heart failure with reduced ejection fraction]
Digoxin therapy is rarely used in modern practice due to its narrow therapeutic window and unclear efficacy. In patients with HFrEF who are optimally treated with primary therapies for HFrEF and vasodilator therapy and who have a low risk of digoxin toxicity (eg, moderate or less severe kidney disease, ability to adhere to periodic monitoring), digoxin can be added to the existing medical regimen. We start with a low dose, obtain frequent monitoring, and if complications or toxicity occur, we cease therapy.

In patients who are already taking digoxin without signs of toxicity, we typically continue digoxin.

[Uptodate : The management of atrial fibrillation in patients with heart failure ]

Acute decompensation : HF treatment & anticoagulation

• Initial resuscitation - diuretics, vasodilators or other measures as appropriate

• acute rate control - < 120bpm을 target

  • HFrEF : IV amiodarone, IV digoxin
    (AF and Acute HF 상황에서는 Betablocker를 사용하지 않음)
    (Diltiazem은 cardiac contractility를 방해할 수 있기 때문에 가능한 피함)

  • HFpEF : who present with congestion or hypotension,
    IV diltiazem (better tolerated with borderline hypotension) or IV Betablocker

• Correction of reversible cause of AF or HF

• We rarely consider an initial cardioversion for treatment of patients with acute decompensated HF

Long term management

• long term anticoagulation

• Rhythm control
  Although the first management approach in acute decompensated AF with HF is often rate control, rhythm control is our preferred long-term management strategy for most patients. This includes patients with recent-onset AF, persistent HF even when rate controlled, or inadequate rate control.

  • Electrical cardioversion / Antiarrhythmic drug therapy / Catheter ablation

• Rate control

  • Betablocker / CCB (LVEF ≥ 40%)

  • Digoxin : In patients who cannot receive a beta blocker or are not adequately rate controlled despite their maximal-tolerated dose, and in whom rhythm control will not be attempted, digoxin may be considered.