Hemodynamic characteristics in patients with permanent atrial fibrillation across different heart rate ranges and left ventricular ejection fraction levels using continuous non-invasive blood pressure monitoring

Aim. Permanent atrial fibrillation (AF) requires rate control. However, the optimal heart rate (HR) remains a matter of debate. Hemodynamic parameters such as mean arterial pressure (MAP) and the proportion of hemodynamically ineffective beats (HIB), derived from pulse pressure (PP), may provide insight into the hemodynamic characteristics of AF at different HRs and left ventricular ejection fractions (LVEF).

Methods. The study included 135 patients with permanent AF (aged 37-90 years, symptom class 1-2A according to the mEHRA scale). For each patient, beat-to-beat systolic BP, diastolic BP, and PP were measured using the “volume clamp” method over a 15-minute period with the “Cardiotechnika-SAKR” system (Incart, Saint Petersburg). On each cardiac cycle, MAP and its variability were calculated using two independent metrics: Average Real Variability (ARV) and Root Mean Square of Successive Differences (RMSSD).

Results. The percentage of HIBs, defined per patient as deviations from the mean PP, considered as 1 («mild» 110 bpm), except 90-110 bpm, HIBs were more frequent in patients with reduced LVEF (110 bpm, MAP was 80.4 ± 12.3 mmHg in the reduced LVEF group versus 94.1 ± 14.1 mmHg in the preserved LVEF group (p0.05).

Conclusion. Heart rate control in permanent AF should be individualized, hemodynamically guided, and account for LVEF. Beat-to-beat monitoring enables identification of the optimal HR that minimizes HIBs and MAP variability while maintaining MAP within accepted reference values, particularly in patients with impaired contractile function.

1. Arakelyan MG, Bokeria LA, Vasileva EYu, et al. Atrial fibrillation and atrial flutter. Clinical guidelines 2020. Russian Journal of Cardiology. 2021;26(7): 4304-4364. (In Russ). https://doi.org/10.15829/1560-4071-2021-4594.

2. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-414. https://doi:10.1093/eurheartj/ehae176.

3. Schkolnikova MA, Shubik YuV, Shalnova SA, et al. Сardiac arrhythmias in the elderly and their association with health characteristics and mortality. Journal of Arrhythmology. 2007;(49):5- 13. (In Russ.).

4. Yakovenko TV, Shubik YuV, Kostyuk GP, Kryatova TV. Quality of life of patients with various forms of atrial fibrillation and the effect of treatment of nosogenic mental reactions on it. Journal of Arrhythmology. 2008;(51): 36-39. (In Russ.).

5. Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362(15): 1363-1373. https://doi:10.1056/NEJMoa1001337.

6. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23): 1825-1833. https://doi:10.1056/NEJMoa021328.

7. Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358(25): 2667-2677. https://doi:10.1056/NEJMoa0708789.

8. Groenveld HF, Tijssen JGP, Crijns HJGM, et al. Rate control efficacy in permanent atrial fibrillation: successful and failed strict rate control against a background of lenient rate control. Data from RACE II. J Am Coll Cardiol. 2013;61(7): 741-748. https://doi: 10.1016/j.jacc.2012.11.038.

9. Mulder BA, Van Veldhuisen DJ, Crijns HJGM, et al. Lenient versus strict rate control in patients with atrial fibrillation and heart failure: a post-hoc analysis of the RACE II study. Eur J Heart Fail. 2013;15(12): 1311-1318. https://doi:10.1093/eurjhf/hft093.

10. Passman R. Rate control for permanent atrial fibrillation: a RACE (II) worth running? J Am Coll Cardiol. 2013;61(7): 749-751. https://doi:10.1016/j.jacc.2012.11.039.

11. Korneev AB, Medvedev MM, Shubik YuV. Elderly patient with syncopal states: a clinical case. Vestn Sankt Peterbg Univ Med. 2024;19(2): 108-117. (In Russ) https://doi:10.21638/spbu11.2024.201.

12. Shubik Yu.V., Pivovarov V.V., Zaitsev G.K., et al. Beat-to-beat blood pressure measurement in atrial fibrillation: a new step towards personalized patient care. Journal of Arrhythmology. 2021;28(1): 23-32. (In Russ). https://doi:10.35336/VA-2021-1-23-32.

13. Penaz J. Patentova Listina. CISLO 133205. 1969.

14. Pivovarov VV, Zaytsev GK, Tichonenko VM, Kormilytsin AYu. A device for measuring blood pressure in the shoulder at each heartbeat. Patent for invention RU 2694737 C1. Date of registration: 10.12.2018. (In Russ.).

15. Pivovarov VV, Zaytsev GK, Tichonenko VM, Kormilytsin AYu. Method for measuring blood pressure in the shoulder at each heartbeat. Patent for invention RU 2698447 C1. Date of registration: 10.12.2018. (In Russ.).

16. Gao Q, Lin Y, Xu R, et al. Association between mean arterial pressure and clinical outcomes among patients with heart failure. ESC Heart Fail. 2023;10(4): 2362-2374. doi:10.1002/ehf2.14401.

17. Samoylov V.O. Medical Biophysics: Textbook for Universities. 3rd ed., rev. and enl. St. Petersburg: SpecLit; 2013. 591 p. (In Russ).

18. Tan Z, Meng H, Dong D, et al. Blood pressure variability estimated by ARV is a predictor of poor short-term outcomes in a prospective cohort of minor ischemic stroke. PLoS One. 2018;13(8): e0202317. https://doi: 10.1371/journal.pone.0202317.

19. Lohman T, Sible I, Shenasa F, et al. Reliability of beat-to-beat blood pressure variability in older adults. Sci Rep. 2024;(14): 18-38. https://doi:10.1038/s41598-024-71183-y.

20. Pivovarov VV, Tichonenko VM, Kormilytsin AYu, Zaytsev GK. System «Cardiotechnika-SAKR» for measuring in each cardiac cycle true blood pressure in the shoulder with its high variability. Outpatient hospital. 2019;(1): 30-32 (In Russ.).

21. Snow T. Consultant radiologist. BMJ. 1996; Apr 6;312(7033): 865.