Improving the diagnosis of heart failure in patients with atrial fibrillation

Karina Bunting, Simrat Gill, Alice Sitch, Samir Mehta, Kieran O'Connor, Gregory Lip, Paulus Kirchhof, Victoria Y Strauss , Kazem Rahimi, A John Camm, Mary Stanbury, Michael Griffith, Jon Townend, Georgios Gkoutos, Andreas Karwath, Richard Steeds, Dipak Kotecha

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)
113 Downloads (Pure)


Objective To improve the echocardiographic assessment of heart failure in patients with atrial fibrillation (AF) by comparing conventional averaging of consecutive beats with an index-beat approach, whereby measurements are taken after two cycles with similar R-R interval. Methods Transthoracic echocardiography was performed using a standardised and blinded protocol in patients enrolled in the RATE-AF (RAte control Therapy Evaluation in permanent Atrial Fibrillation) randomised trial. We compared reproducibility of the index-beat and conventional consecutive-beat methods to calculate left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and E/e' (mitral E wave max/average diastolic tissue Doppler velocity), and assessed intraoperator/interoperator variability, time efficiency and validity against natriuretic peptides. Results 160 patients were included, 46% of whom were women, with a median age of 75 years (IQR 69-82) and a median heart rate of 100 beats per minute (IQR 86-112). The index-beat had the lowest within-beat coefficient of variation for LVEF (32%, vs 51% for 5 consecutive beats and 53% for 10 consecutive beats), GLS (26%, vs 43% and 42%) and E/e' (25%, vs 41% and 41%). Intraoperator (n=50) and interoperator (n=18) reproducibility were both superior for index-beats and this method was quicker to perform (p<0.001): 35.4 s to measure E/e' (95% CI 33.1 to 37.8) compared with 44.7 s for 5-beat (95% CI 41.8 to 47.5) and 98.1 s for 10-beat (95% CI 91.7 to 104.4) analyses. Using a single index-beat did not compromise the association of LVEF, GLS or E/e' with natriuretic peptide levels. Conclusions Compared with averaging of multiple beats in patients with AF, the index-beat approach improves reproducibility and saves time without a negative impact on validity, potentially improving the diagnosis and classification of heart failure in patients with AF.

Original languageEnglish
Pages (from-to)902-908
Number of pages7
Issue number11
Early online date10 Mar 2021
Publication statusPublished - 12 May 2021


  • atrial fibrillation
  • diastolic
  • echocardiography
  • heart failure
  • systolic

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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