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

• Published in: Heart (British Cardiac Society) Vol. 111; no. 8; pp. 362 - 369
• Main Authors: Abdali, Zainab, Bunting, Karina V, Mehta, Samir, Camm, John, Rahimi, Kazem, Stanbury, Mary, Haynes, Sandra, Kotecha, Dipak, Jowett, Sue
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd and British Cardiovascular Society 01.04.2025; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: 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; United Kingdom; United Kingdom > UK; Health Care Economics and Organizations; Atrial Fibrillation; Quality of Health Care
• ISSN: 1355-6037; 1468-201X; 1468-201X
• DOI: 10.1136/heartjnl-2024-324761

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.