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Digoxin for rheumatic heart disease: a cautious future for a drug from the past?
  1. Bruno R Nascimento1,2,
  2. Andrea Z Beaton3
  1. 1Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  2. 2Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  3. 3Cardiology Department, Children’s National Health System, Washington, District of Columbia, USA
  1. Correspondence to Dr Bruno R Nascimento, Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena,190, room 246, Belo Horizonte, Minas Gerais 30130-100, Brazil; ramosnas{at}gmail.com

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Rheumatic heart disease (RHD) is the late sequelae of inadequately treated group A streptococcal pharyngeal infections, leading to acute rheumatic fever, a multisystem immune response that often culminates in valvular damage and ultimately heart failure (HF).1 While advanced rheumatic valvular disease is ideally treated with interventional procedures (surgical or percutaneous), the reality is that access to these procedures is severely constrained in many RHD-endemic areas, limiting patients to medical management for symptom control.2

There are very limited data on the best practices for medical management of RHD, with most recommendations drawn from what is known from the general literature on HF, supraventricular arrhythmias and valvular heart disease. This is problematic because the population of patients with RHD is both younger and less likely to have secondary cardiac risk (such as coronary artery disease and hypertension) as compared with the general HF and valvular heart disease communities. In addition, cardiac involvement by RHD has some particularities that impact mortality, such as the frequent association with atrial fibrillation (AF) and flutter, which may influence therapeutic response and change outcomes.2

Newly, a large, multinational Global Rheumatic Heart Disease Registry (REMEDY) has provided the power to study therapeutics specifically in patients with RHD. The registry contains data on over 3300 patients with RHD, the majority living in low-income and middle-income countries, and half (51%) with advanced valvular heart disease at enrolment. While the data are exclusively observational—no therapeutics were guided by or changed by registry participation—REMEDY provides some of the first data on therapeutic practices and response among a large RHD-affected population.3

In Heart, we get the chance to review the first therapeutics paper to emerge from the REMEDY study; the use and effectiveness of digoxin.3 While digoxin (digitalis) is one of the oldest known cardiovascular drugs, its contemporary risk:benefit ratio …

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