The derivatives of digitalis in the foxglove, especially digoxin, as pioneered by William Withering, still have a place in clinical cardiology, albeit now with controversy and insecurity in usage, especially by younger physicians. However, digoxin must be used by skilled and committed clinicians who will carefully monitor serum levels of the medication. The safest digoxin levels appear to be ≤ 1.0 ng/ml, with no advantage from higher levels. The narrow therapeutic window means that experience and skill are required for the use of digoxin. It is most doubtful that any metaanalysis or observational study are sufficiently controlled or will be able to control for these precise variables. The strongest support for the use of digoxin is when rate control is planned for a patient with AF with a rapid ventricular response and concomitant relative hypotension, since all the other rate control medications such as metoprolol, diltiazem, and verapamil contribute to the lowering of blood pressure. Nevertheless, when usage is precise, it also appears appropriate for select clinicians to continue to consider and use the foxglove as an adjunct to current accepted therapy for CHF when the desired clinical status is not attained.
The author thanks Colleen McMullen, MA, MBA, for her excellent editorial critique.
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Am J Cardiovasc Drugs. 2018;18(6):427-440. © 2018 Adis Springer International Publishing AG