title: The assessment of autonomic function in chronic atrial fibrillation: description of a non-invasive technique based on circadian rhythm of atrioventricular nodal functional refractory periods.
abstract: OBJECTIVE
  Heart rate variability (HRV) parameters can be used to assess autonomic function and to predict outcome, but this has been done exclusively in patients with sinus rhythm. Atrial fibrillation (AF) is the commonest sustained arrhythmia and is particularly prevalent in heart failure. We have developed a simple index to assess autonomic function in patients with chronic AF.
  
  
  RESULTS
  Forty patients with chronic AF (>1 month) and symptoms of heart failure underwent ambulatory 24 h electrocardiography recording as well as evaluation of symptoms, exercise capacity (6 min walk distance), ventricular function (echocardiography and radionuclide ventriculography), and neuroendocrine activation. A number of standard HRV parameters shown to have prognostic significance in sinus rhythm were also determined. A modified in-house HRV statistical programme was used to filter labelled QRS intervals and to compute the 5th percentile RR interval in each hour. This parameter has been shown to approximate the functional refractory period (FRP) of the atrioventricular node (AVN). A cosine curve was fitted to hourly 5th percentile RR intervals for each patient and from this was estimated the diurnal change in hourly 5th percentile RR interval (approximating DeltaFRP of the AVN) and, by inference, diurnal variation in sympathovagal input to the AVN. Digoxin was the sole agent permitted for control of ventricular rate. DeltaFRP of the AVN varied and revealed a significant correlation, on multivariate analysis, with mean RR interval (P<0.001), SDARR (SD of 5-min average RR intervals during 24 h, P<0.001), and NYHA class of heart failure (classes III and IV heart failure vs. classes I and II, P=0.02). SDARR has previously been shown independently to predict mortality in patients with chronic AF and heart failure.
  
  
  CONCLUSIONS
  This analysis describes a novel non-invasive method for assessing autonomic function in chronic AF. Whether DeltaFRP in chronic AF patients can independently predict adverse prognosis or sudden death requires further study.
authors.affiliation: Academic Unit of Cardiology, University of Hull, Hull, UK. akhand31@aol.com
authors.forename: Aleem U
authors.initials: AU
authors.lastname: Khand
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Rankin
authors.forename: John G F
authors.initials: JG
authors.lastname: Cleland
authors.forename: Islay
authors.initials: I
authors.lastname: Gemmell
authors.forename: Elaine
authors.initials: E
authors.lastname: Clark
authors.forename: Peter W
authors.initials: PW
authors.lastname: Macfarlane
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology*; D001283:Atrioventricular Node / Q000503:physiopathology*; D001342:Autonomic Nervous System Diseases / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology*; D002908:Chronic Disease; D002940:Circadian Rhythm; D003936:Diagnosis, Computer-Assisted / Q000379:methods; D015716:Electrocardiography, Ambulatory / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D012032:Refractory Period, Electrophysiological; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity