Which drug is not recommended as first-line therapy for atrial fibrillation or heart failure in older adults?

• A. Sotalol
• B. Amiodarone
• C. Digoxin
• D. Diltiazem

Answer: (C)

Digoxin is not considered first-line in older adults for either atrial fibrillation or heart failure because its benefits are limited to symptom control and it does not improve survival, while its safety margin is narrow and worsens with age and reduced kidney function. For AF, rate control is typically achieved with beta-blockers or non-dihydropyridine calcium channel blockers, which have clearer benefits and safer profiles in most older patients. For heart failure, the treatments that demonstrably reduce mortality—such as ACE inhibitors or ARBs or ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors—are preferred, with antiarrhythmic choices like amiodarone used selectively. Digoxin may help with rate control when other therapies are insufficient or contraindicated, but it is not the preferred first option due to lack of mortality benefit and higher toxicity risk in this population.