* 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
0%
10%
20%
30%
40%
50%
60%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
PercentageofDigoxinuse/admissionsperyear

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