Rethinking digoxin in pediatric heart failure

* Raysa Morales-Demori, MD

Type of study: Retrospective cohort study
Database: Pediatric Health Information System
Study period: 01/2004 – 12/2017
Inclusion criteria:
All patients ≤ 21 year
Heart failure diagnoses ICD-9 (428.xx) or ICD-10 (i50.xx)

Digoxin use was associated with decreased inpatient mortality
In patients with CHD (24% vs 76%, p<0.001)
In Extreme Risk of Mortality (17% vs 83%, p<0.001)

1. Rethinking digoxin use in pediatric heart failure across the US Raysa Morales-Demori, MD; Marc Anders, MD Department of Pediatrics. Section of Critical Care Baylor College of Medicine. Texas Children’s Hospital

2. 2 Background Digoxin works by inhibiting Na + -K + ATPase Not first line treatment for heart failure Associated with decreased inter stage mortality in pediatric single ventricle patients Adult literature has reported decreased heart failure related hospital admissions Rossano , et al. Pediatr Crit Care Med. 2016 Oster, et al. J Am Heart Assoc. 2016

3. 3 Objective To describe the profile and inpatient outcome of digoxin use in pediatric heart failure

4. 4 Methods Type of study : Retrospective cohort study Database : Pediatric Health Information System Study period : 01/2004 – 12/2017 Inclusion criteria : All patients ≤ 21 year Heart failure diagnoses ICD-9 (428.xx) or ICD-10 (i50.xx)

5. 5 Trend of digoxin use

6. 6 Demographics Digoxin (+) n 19,506 Digoxin (-) n 57,140 P value Male, n (%) 10,291 (53%) 29,758 (52%) 0.25 Age, median in months (IQR 25-75) 5.6 (1.7-64.9) 7.8 (2.4-69.2) p <0.0001 Race/ethnicity p <0.0001 White Non-Hispanics, n (%) 12,386 (64%) 29,045 (51%) Hispanics, n (%) 3,810 (20%) 11,975 (21%) African American Non-Hispanics, n (%) 2,168 (11%) 7,846 (14%) Congenital Heart disease (CHD), n (%) 14,935 (77%) 42,635 (75%) p <0.0001 Mortality risk p <0.0001 Minor, n (%) 1,543 (8%) 4,147 (7%) Moderate, n (%) 6,897 (35%) 18,867 (33%) Major, n (%) 7,876 (40%) 23,363 (41%) Extreme, n (%) 3,158 (16%) 10,626 (19%)

7. 7 Outcomes Digoxin (+) n 19,506 Digoxin (-) n 57,140 OR (CI 95%) P value Inpatient mortality, n (%) 1,244 (6%) 5,105 (9%) 0.69 (0.65-0.74) < 0.0001 Hospital admissions, median in days (IQR 25-75) 2 (1-3) 1 (1-2) 1.62 (1.56-1.67) < 0.0001 Hospital LOS, median in days (IQR 25-75) 13 (5-35) 9 (5-24) < 0.0001 ICU admission, n (%) 14,554 (75%) 45,232 (79%) 0.77 (0.75-0.80) < 0.0001 ICU LOS, median in days (IQR 25-75) 4 (0-15) 3 (0-10) < 0.0001 Billed hospitalization charges, median in US$ (IQR 25-75) 142,244 (43,807-426,544) 153,290 (63,202-398,370) < 0.0001 Mechanical ventilation, n (%) 14,554 (54%) 45,232 (79%) 0.72 (0.70-0.75) < 0.0001 Other vasoactive medication, n (%) 13,412 (69%) 41,283 (72%) 0.84 (0.81-0.88) < 0.0001

8. 8 Outcomes Digoxin (+) n 19,506 Digoxin (-) n 57,140 OR (CI 95%) P value Surgical procedures, n (%) 10,182 (52%) 32,314 (57%) 0.83 (0.81-0.87) < 0.0001 Pre-operative LOS, median in days (IQR 25-75) 5 (1-14) 1 (0-6) < 0.0001 Post-operative LOS, median in days (IQR 25-75) 16 (7-38) 10 (5-26) < 0.0001 Surgical complications, n (%) 5,517 (54%) 16,836 (52%) 1.08 (1.04-1.14) < 0.0001 ECMO, n (%) 1,007 (5%) 3,556 (6%) 0.82 (0.76-0.88) < 0.0001 VAD placement, n (%) 251 (1%) 713 (1%) 1.03 (0.89-1.19) 0.68 Heart transplantation, n (%) 822 (4.2%) 2,050 (3.5%) 1.18 (1.09-1.28) < 0.0001

9. 9 Outcomes Digoxin use was associated with decreased inpatient mortality In patients with CHD (24% vs 76%, p<0.001) In Extreme Risk of Mortality (17% vs 83%, p<0.001)

10. 10 Conclusions There has been a significant downtrend of digoxin use in the pediatric heart failure population across the USA over time that has remained stable since 2014 Digoxin was associated with decreased inpatient mortality in pediatric HF, especially in those patients with CHD and extreme mortality risk