Has digoxin been pushed aside too soon in modern heart failure care?

In this episode of Beatwise The Podcast, I speak with Prof. John Cleland about the evolving evidence for digoxin and other digitalis glycosides in heart failure, and whether these long-established treatments still have a role alongside contemporary guideline-directed medical therapy.

We revisit the original DIG trial and explore why digoxin fell out of favour, from concerns around sudden cardiac death and arrhythmias to the arrival of newer heart failure therapies. Prof. Cleland explains how modern treatments including beta blockers, MRAs, ARNi, SGLT2 inhibitors and device therapy may change the risk-benefit equation.

We also discuss the important differences between digoxin and digitoxin, how digitalis glycosides work, and new evidence that is prompting clinicians to take another look at this old class of drugs. 

So where might digoxin fit into heart failure management today?

Prof. Cleland shares his perspective on its potential role as an additional therapy for patients with HFrEF who remain symptomatic despite guideline-directed treatment, as well as its use in congestion and atrial fibrillation. We also explore the evidence in patients with HFpEF and AF, including findings from RATE-AF, and what the DECISION trial adds to the debate.

Finally, we discuss practical considerations around digoxin dosing and monitoring - and why Prof. Cleland believes the question of digoxin’s role in modern heart failure care still deserves a definitive large-scale clinical trial.

Key issues addressed:

• Why digoxin fell out of favour in heart failure care
• Digoxin vs digitoxin: what is the difference?
• How digitalis glycosides work in heart failure
• What the original DIG trial actually showed
• How modern heart failure therapy may change the safety of digoxin
• The role of digoxin in HFrEF despite guideline-directed medical therapy
• Digoxin for atrial fibrillation and heart-rate control
• What RATE-AF tells us about digoxin vs beta blockers in HFpEF and AF
• Whether digoxin has a role in managing congestion
• The latest evidence from DECISION and contemporary digitalis trials
• Digoxin dosing, therapeutic levels and monitoring
• Why we may need a large, pragmatic digoxin trial

EPISODE HIGHLIGHTS:

00:00 The Comeback of Digoxin?

00:50 Introducing Prof. John Cleland

01:33 Digoxin vs Digitoxin: What’s the Difference?

02:27 How Digitalis Glycosides Work

03:13 What Did the DIG Trial Show?

04:50 Why Did Digoxin Fall Out of Favour?

06:55 Has Modern Heart Failure Therapy Changed the Risk?

07:39 Who Should Receive Digoxin Today?

08:34 Digoxin in HFrEF and Sinus Rhythm

10:39 Digoxin and Atrial Fibrillation

11:37 HFpEF, AF and the RATE-AF Trial

13:24 Can Digoxin Help with Congestion?

16:22 The DECISION Trial and Current Guidelines

17:24 Low Blood Pressure and Advanced Heart Failure

19:11 Digoxin Dosing and Monitoring

20:57 Does Digoxin Need a New Mega-Trial?

23:43 Final Thoughts

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

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Disclaimer: This sponsored episode of Beatwise has been independently developed and produced by Beatwise, with financial support from Bayer. Bayer has no role in speaker selection or in developing the content. This episode is strictly non-promotional and contains no discussion or reference to prescription-only medicines.

In this episode of Beatwise The Podcast, I speak with Helen Kilminster about a topic that may not sound exciting at first but has huge implications for patient care: heart failure coding.

We explore why accurate NHS coding is about far more than administration. The way heart failure is identified and coded influences everything from disease prevalence and service planning to funding, workforce, and access to specialist clinics. In particular, we discuss why heart failure with preserved ejection fraction (HFpEF) remains under-recognised despite accounting for around half of all heart failure cases.

Helen shares her experience working in primary care, describing how audits, weekly data tracking, and careful review of investigations such as echocardiograms and NT-proBNP can help identify patients who may otherwise be missed. We also discuss the challenges of variable discharge summaries, the importance of clear communication between primary and secondary care, and how better coding can support earlier diagnosis and more proactive management.

Finally, we explore how these ideas align with the NHS 10-Year Plan, including community-based care, technology-enabled monitoring, integrated neighbourhood teams, and whether concepts such as "pre-heart failure" coding could help identify high-risk patients before they develop advanced disease.

Key issues addressed:

• Why accurate heart failure coding matters
• Why HFpEF is frequently missed in clinical practice
• How coding influences funding, workforce and specialist services
• The role of primary care audits in identifying undiagnosed HFpEF
• Improving communication between primary and secondary care
• Community screening initiatives and raising awareness of heart failure
• The NHS 10-Year Plan and the future of integrated heart failure care
• Whether "pre-heart failure" coding could support earlier intervention and prevention

Whether you work in primary care, secondary care, or have an interest in heart failure services, this episode highlights why improving identification and coding is fundamental to delivering better care for patients.

EPISODE HIGHLIGHTS:

00:00 Coding sounds boring... but it isn't

01:05 Meet today's guest

03:02 Why HFpEF gets missed

03:26 The reality of heart failure audits in primary care

06:01 Complex patients need joined-up pathways

08:24 The cost of inaccurate coding

10:02 Community screening and awareness initiatives

12:53 How the NHS 10-Year Plan could transform care

16:24 How secondary care can improve coding and communication

20:08 Why discharge summaries matter

24:03 Could "pre-heart failure" coding improve prevention?

26:24 Helen's elevator pitch for improving heart failure care

28:12 Wrap up and final thoughts

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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In this episode of Beatwise The Podcast, I speak with Dr Brian Halliday about one of the biggest advances in the treatment of obstructive hypertrophic cardiomyopathy (HCM): cardiac myosin inhibitors.

For decades, treatment has focused on managing symptoms with medications such as beta blockers, verapamil and disopyramide, alongside septal reduction therapies for selected patients. We explore how cardiac myosin inhibitors represent a different approach by targeting the underlying hypercontractility that drives left ventricular outflow tract obstruction.

We discuss the science behind these therapies, how they work at a molecular level, and the evidence from landmark clinical trials including EXPLORER-HCM, VALOR-HCM and SEQUOIA-HCM. Dr Halliday explains what these studies have taught us about symptom improvement, exercise capacity, left ventricular outflow tract gradients and the potential to reduce the need for invasive septal reduction therapy.

We also discuss how these treatments are being introduced into clinical practice, including patient selection, specialist referral pathways, echocardiographic monitoring, and what the future may hold for patients with both obstructive and non-obstructive HCM.

Key issues addressed:

• Traditional treatment options for obstructive HCM
• How cardiac myosin inhibitors work
• The evidence from EXPLORER-HCM, VALOR-HCM and SEQUOIA-HCM
• Myosin inhibitors versus beta blockers
• Referral pathways, monitoring and prescribing in the UK
• Future directions for HCM treatment

Whether you care for patients with HCM or live with the condition yourself, this episode provides an overview of how treatment is evolving and what these new therapies may mean for the future.

EPISODE HIGHLIGHTS:

00:00 Welcome and episode focus

01:02 Traditional HCM treatments

02:46 How myosin inhibitors work

06:26 Landmark mavacamten trials

10:23 Aficamten and new evidence

11:45 Beta blockers versus myosin inhibitors

16:19 Referral pathways and monitoring

20:33 NHS prescribing and echocardiographic follow-up

21:42 Future of HCM treatment

23:44 Wrap up

24:35 Final thanks and subscribe

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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Heart failure, chronic kidney disease (CKD) and metabolic disease are deeply interconnected, yet healthcare systems have traditionally treated them as separate conditions. In this episode of Beatwise, I’m joined by Dr Andrew Frankel, Consultant Nephrologist at Imperial College Healthcare NHS Trust, to explore why cardiorenal metabolic (CRM) medicine is transforming how we care for patients.

We discuss the shared biology linking heart, kidney and metabolic disease, why "creatinine fear" continues to prevent optimal treatment, and how therapies such as SGLT2 inhibitors, finerenone and GLP-1 receptor agonists are reshaping outcomes across multiple specialties.

We also explore the future of integrated cardiorenal care, including multidisciplinary services, workforce education, patient-centred CRM hubs and what healthcare systems need to do next to improve outcomes while reducing fragmentation of care.

Key topics discussed: 

• Why cardiorenal metabolic disease should be viewed as a single disease process rather than separate conditions
• The common pathophysiology linking heart failure, CKD and metabolic disease
• The problem with "creatinine fear" and premature discontinuation of life-saving therapies
• The four pillars of modern cardiorenal metabolic treatment
• Practical prescribing tips for SGLT2 inhibitors, including eGFR thresholds and sick day rules
• Hyperkalaemia as a barrier to guideline-directed medical therapy and how to overcome it
• The role of finerenone and non-steroidal MRAs in cardiorenal care
• Why GLP-1 receptor agonists offer benefits far beyond weight loss
• How integrated cardiorenal services can improve patient outcomes and reduce healthcare costs
• The future of CRM hubs and one-stop multidisciplinary care pathways

About my guest:

Dr Andrew Frankel is a Consultant Nephrologist at Imperial College Healthcare NHS Trust and a leading advocate for integrated kidney care, cardiorenal medicine and workforce education. He is also co-host of the educational podcast For Kidneys' Sake, which provides practical updates on chronic kidney disease and cardiorenal metabolic care.

EPISODE HIGHLIGHTS:

00:00 Welcome and Guest Introduction

01:29 Why Cardiorenal Medicine Matters

03:14 Creatinine Fear and GFR Misconceptions

04:31 The Four Pillars of Cardiorenal Therapy

07:53 Practical Use of SGLT2 Inhibitors

10:58 Hyperkalaemia as a Barrier to Treatment

14:22 Building Integrated Cardiorenal Services

19:04 Specialist Roles and Shared Care

20:40 GLP-1 Receptor Agonists and New Weight-Loss Therapies

23:33 Lifestyle Medicine and CRM Hubs

26:28 Closing Reflections

28:41 Final Thanks and Subscribe

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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In this episode of BeatWise The Podcast, I am joined by Professor Joseph Selvanayagam to explore cardiac metabolism in hypertrophic cardiomyopathy (HCM), the evolving treatment landscape in HCM, and the findings of the RESOLVE-HCM trial investigating perhexiline in non-obstructive disease.

We explore the heterogeneity of HCM, including the differences between obstructive and non-obstructive forms of the condition, why symptoms are not always explained by LV outflow tract obstruction alone, and how treatment strategies are beginning to move beyond symptom management toward disease-modifying therapies.

We also discuss the role of myocardial energetics and metabolic dysfunction in HCM, how perhexiline works as a CPT1 inhibitor to shift myocardial metabolism toward more oxygen-efficient glucose use, and why this may be particularly relevant in non-obstructive HCM where treatment options remain limited.

Professor Selvanayagam takes us inside the design of the randomized, double-blind RESOLVE-HCM trial, including the use of cardiac MRI imaging and maximal LV wall thickness as the primary endpoint over 12 months. We review the trial findings, where several endpoints including diastolic function, NT-proBNP, and quality-of-life measures favored perhexiline, with mental health quality-of-life outcomes reaching statistical significance.

We also explore the importance of therapeutic drug monitoring given perhexiline’s narrow therapeutic index, the risks of hepatotoxicity and neurotoxicity, and the future direction of metabolic therapies in cardiomyopathy.

Key topics discussed: 

• Obstructive vs non-obstructive HCM
• What drives symptoms in hypertrophic cardiomyopathy
• The evolution of HCM therapies
• Cardiac metabolism and myocardial energetics
• How perhexiline works
• The RESOLVE-HCM trial
• Cardiac MRI endpoints in HCM research
• Therapeutic drug monitoring and safety
• Disease-modifying therapies in cardiomyopathy

EPISODE HIGHLIGHTS:

00:00 Welcome to Beatwise

00:27 Why metabolism matters

01:59 Meet Professor Selvanayagam

02:29 HCM types and symptoms

04:29 Treatment landscape update

05:42 Why RESOLVE-HCM

07:20 How perhexiline works

08:44 Trial design and imaging

12:53 RESOLVE-HCM results

14:43 Clinical use and safety

17:15 Future trials and wrap up

18:54 Final takeaways

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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In this episode of Beatwise The Podcast, I speak with Dr Archana Ganapathy about a problem we don’t talk about enough in heart failure: congestion that we can’t properly see.

Many patients leave hospital still fluid overloaded at a tissue level - despite looking “better” clinically. And that gap is part of why readmissions and outcomes remain poor. We discuss why current tools - from clinical exam to imaging and biomarkers - often fall short, and why understanding where fluid sits in the body matters just as much as how much is there.

We then explore bioimpedance: what it is, how it works at the bedside, and why it may offer a more objective way to guide treatment. Dr Ganapathy also shares early insights from the BioHF trial, including what happens when fluid management is guided by measurement rather than estimation.

For further context, Dr Ganapathy’s recent review on congestion assessment in decompensated heart failure is linked here: Advances in Congestion Assessment in Decompensated Heart Failure

Key issues addressed: 

• Why “hidden” congestion is so common in heart failure
• The limitations of weight, BNP, imaging and clinical exam
• Why fluid distribution matters
• How bioimpedance works in practice
• Early findings from the BioHF trial

If you care for patients with heart failure - or live with it - this is worth understanding.

EPISODE HIGHLIGHTS:

00:00 Hidden congestion problem

02:00 Why assessment falls short

05:05 Fluid location matters

07:02 Promise of bioimpedance

08:54 How bioimpedance works

13:06 BioHF trial design

17:16 Early findings & future impact

22:29 Recruitment & next steps

23:06 Wrap up

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

Thank you to Maltron International Limited for sponsoring this episode.

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In this episode of Beatwise The Podcast, I speak with Helen Kilminster - Senior Pharmacist ACP and Deputy PCN Clinical Director -  about a part of heart failure care that is often overlooked: coding. We explore a part of heart failure care that is often overlooked: coding. Not as an administrative task - but as something that directly shapes patient outcomes. Because if heart failure isn’t coded accurately, it often isn’t fully visible. Patients are missed, risk isn’t under-recognised, and opportunities for earlier intervention are lost.

We discuss how coding underpins everything from diagnosis to commissioning - and why small inconsistencies in how heart failure is recorded can have system-wide consequences. Helen shares how practices are identifying missed patients through NT-proBNP testing and case-finding, how coding supports risk stratification alongside comorbidities, and why clearer communication between cardiology and primary care is essential.

We also explore the challenges of inconsistent terminology, and the importance of correctly coding NICE-defined heart failure subtypes - HFrEF, mildly reduced EF, and HFpEF - to ensure patients receive appropriate care.

Key issues addressed:

• Why heart failure coding directly affects diagnosis and outcomes
• How GP coding systems work in practice
• The problem of inconsistent terminology across care settings
• Why NICE heart failure subtypes need to be clearly coded
• Using NT-proBNP and case-finding to identify missed patients
• How coding informs funding, commissioning, and service design
• Tools to support better coding
• The role of communication between primary and secondary care

This episode is produced in collaboration with the British Society for Heart Failure.

EPISODE HIGHLIGHTS:

00:00 Why coding matters

01:40 How GP coding works

04:33 Finding missed heart failure

06:20 Sharing codes across care

08:27 Contracts and subtypes

11:49 Defining heart failure types

13:48 Tools for better coding

17:35 Funding and commissioning

23:54 NHS reform and teams

28:59 Patient impact and equity

33:23 Practical coding tips

37:05 Final takeaways

FURTHER LEARNING:

• NICE Guidance
• OpenPrescribing
• OpenCodelists
• British Society for Heart Failure

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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In this episode of Beatwise The Podcast, I speak with Paul Pozzo, a leading patient advocate and former chair of Amyloidosis UK. Paul shares his experience living with wild-type amyloidosis, from the challenges of delayed diagnosis to becoming a powerful voice for patients in research and healthcare advocacy.

Diagnosed in 2015 at a time when no disease-modifying drugs were available, Paul was initially treated with standard heart failure therapies before later joining clinical trials that helped stabilize his condition and improve his quality of life.

Together, we explore the critical role of patient advocacy in rare diseases, the need for earlier diagnosis, and how research participation is helping transform outcomes for people with amyloidosis.

We also discuss the importance of recognising early warning signs, including:

• unexplained breathlessness
• carpal tunnel syndrome
• neuropathy
• kidney problems
• and the finding of a “thick heart” on cardiac imaging

Beyond diagnosis and treatment, the conversation highlights the need for holistic care, including multidisciplinary support, cardiac rehabilitation, and attention to mental wellbeing. Paul also explains how patient organisations like Amyloidosis UK provide vital support through education, community connections, and advocacy, helping patients and families navigate what can often be a complex and isolating diagnosis.

This episode is an important reminder that patient voices play a crucial role in shaping research, improving care pathways, and raising awareness of rare cardiac conditions.

EPISODE HIGHLIGHTS:

00:00 Welcome to Beatwise

01:01 Paul’s Diagnosis Story

03:32 Living With Limitations

06:24 Why Early Diagnosis Matters

07:36 Red Flags and Patient Voice

09:34 How the Charity Helps

11:09 Research and Clinical Trials

13:46 Symptoms and Hospital Journey

17:05 Reassurance After Diagnosis

21:01 Holistic Care and Rehab

24:11 Call to Action and Charities

30:05 Final Takeaways and Thanks

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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In this episode of Beatwise The Podcast, I, Dr. Sarah Birkhoelzer, explore the uncomfortable but essential topic of sexism, sexual harassment, and sexual assault in healthcare. I am joined by Dr. Becky Cox and Dr. Chelcie Jewitt, founders of Surviving in Scrubs, a movement created to expose and address sexual misconduct within medical training and clinical environments.

Together, we discuss the realities many healthcare professionals face behind closed doors - from everyday sexism to serious violations - and why these experiences so often go unreported. The conversation examines the scale of the problem, the systemic and cultural factors that allow it to persist, and the real consequences for staff wellbeing, workforce retention, and patient care. Dr. Cox and Dr. Jewitt also share how Surviving in Scrubs began, what the data tells us, and what meaningful change actually looks like - from safer reporting mechanisms to institutional accountability and allyship.

This episode is a call to awareness, responsibility, and action for individuals, organisations, and the healthcare system as a whole.

EPISODE HIGHLIGHTS:

00:00 Introduction to Beatwise The Podcast

00:58 Meeting the founders of Surviving in Scrubs

02:38 How Surviving in Scrubs began

06:33 The scale of sexism and sexual harassment in healthcare

15:32 Impact on healthcare professionals and patient care

18:07 Progress so far and future goals

24:46 What individuals and institutions can do

30:28 Key takeaways and closing reflections

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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Atrial fibrillation (AF) is one of the most common heart rhythm conditions, yet it’s often misunderstood and overwhelming for patients when they first hear the diagnosis. In this episode of Beatwise the Podcast, I’m joined by Dr. Maria Steuden, consultant electrophysiologist, to break down what atrial fibrillation really means, how it’s treated, and what patients can expect at each stage of their journey.

Together, we explain the different treatment options - from medications to procedures such as cardioversion, catheter ablation, and pace-and-ablate - and discuss how decisions are tailored to each individual. We also cover the crucial role of anticoagulation in stroke prevention, how AF can interact with heart failure, and the importance of lifestyle factors in managing symptoms and long-term risk.

This episode is designed to give patients and families clear, evidence-based information, so they feel informed, reassured, and better equipped to take part in decisions about their care.

• What atrial fibrillation is and how it affects the heart
• Common symptoms and how AF is diagnosed
• Medication options for rhythm and rate control
• Why anticoagulation is so important for stroke prevention
• Cardioversion, AF ablation, and pace-and-ablate - what these procedures involve
• The link between atrial fibrillation and heart failure
• How lifestyle and risk factor management can support AF treatment
• Why AF progression and treatment look different for every patient

EPISODE HIGHLIGHTS:

00:00 – Introduction to atrial fibrillation

01:12 – What atrial fibrillation is and how it develops

01:45 – Medications used in AF management

06:24 – Risk factors and anticoagulation

09:36 – Procedural treatment options for AF

19:10 – Atrial fibrillation and heart failure

22:43 – The patient journey and prevention strategies

25:15 – Key takeaways

27:45 – Closing thoughts and next steps

If you enjoyed this episode, please like, rate, and subscribe to Beatwise The Podcast. Your support helps me reach more listeners and continue providing valuable content.

Don't forget to follow me on social media @sarah.theheartdoc for the latest updates, behind-the-scenes content, and more engaging discussions. Stay connected and be part of our growing community!

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