Journal Article

Cost-effectiveness of digoxin versus beta blockers in permanent atrial fibrillation: the Rate Control Therapy Evaluation in Permanent Atrial Fibrillation (RATE-AF) randomised trial

Haynes, Sandra, Stanbury, Mary, Camm, John, Abdali, Zainab, Rahimi, Kazem, Jowett, Sue, Mehta, Samir, Bunting, Karina V, Kotecha, Dipak

2025

Overview

BackgroundAtrial fibrillation (AF) is a major and increasing burden on health services. This study aimed to evaluate the cost-effectiveness of digoxin versus beta-blockers for heart rate control in patients with permanent AF and symptoms of heart failure.MethodsRAte control Therapy Evaluation in permanent Atrial Fibrillation (RATE-AF) was a randomised, open-label, blinded, endpoint trial embedded in the UK National Health Service (NHS) to directly compare low-dose digoxin with beta-blockers (ClinicalTrials.gov: NCT02391337). A trial-based cost-utility analysis was performed from a healthcare perspective over 12 months. Resource use in primary and secondary healthcare services, medications and patient-reported quality of life were prospectively collected to estimate differences in costs and quality-adjusted life years (QALYs).ResultsRATE-AF randomised 160 patients with mean age of 76 (SD 8) years and 46% women, of which 149 patients (n=73 digoxin, n=76 beta blockers) had complete data and survived to 12-month follow-up. Treatment with digoxin was significantly less costly, with a mean saving of £530.41 per patient per year (95% CI −£848.06 to −£249.38, p=0.001). This was principally due to substantially lower rates of adverse events, with less primary and secondary healthcare utilisation compared with beta-blocker therapy. There was no significant difference in QALYs (0.013; 95% CI −0.033 to 0.052, p=0.56). At the £20 000 per-QALY willingness to pay threshold, the probability of digoxin being cost-effective compared with beta-blockers was 94%, with potential annual savings to the NHS of £102 million/year (95% CI £48 million to £164 million saving, p=0.001).ConclusionsDigoxin is a less costly option when compared with beta-blockers for control of heart rate in suitable patients with permanent AF, with larger cost-effectiveness studies warranted to advise on national and global policy-making.Trial registration number NCT02391337, EudraCT 2015-005043-13.

• Publisher: BMJ Publishing Group Ltd and British Cardiovascular Society,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Adrenergic beta-Antagonists - administration & dosage / Adrenergic beta-Antagonists - adverse effects / Adrenergic beta-Antagonists - economics / Adrenergic beta-Antagonists - therapeutic use / Aged / Aged, 80 and over / Anti-Arrhythmia Agents - administration & dosage / Anti-Arrhythmia Agents - adverse effects / Anti-Arrhythmia Agents - economics / Anti-Arrhythmia Agents - therapeutic use / Atrial Fibrillation / Atrial Fibrillation - drug therapy / Atrial Fibrillation - economics / Atrial Fibrillation - physiopathology / Beta blockers / Cardiac arrhythmia / Cost analysis / Cost control / Cost-Benefit Analysis / Digoxin - administration & dosage / Digoxin - adverse effects / Digoxin - economics / Digoxin - therapeutic use / Drug Costs / Economic analysis / Female / Health care / Health Care Economics and Organizations / Health services / Healthcare Delivery, Economics and Global Health / Heart failure / Heart rate / Heart Rate - drug effects / Hospitals / Humans / Male / Original Research / Patient admissions / Primary care / Prospective Studies / Quality of Health Care / Quality of Life / Quality-Adjusted Life Years / Questionnaires / Treatment Outcome / United Kingdom