Development and application of a novel holter-based algorithm to quantify ventricular irregularity in atrial fibrillation: prognostic implications in heart failure with preserved ejection fraction
C Chaumont, L Ramos, A Savoure, R Al Hamoud, C Fauvel, H Eltchaninoff, F AnselmeAbstract
Introduction
Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent and remains a major cause of hospitalization. Atrial fibrillation (AF) frequently coexists with HFpEF, a combination associated with worse outcomes. Beat-to-beat ventricular irregularity in AF has deleterious hemodynamic effects, yet conventional Holter indices—developed for sinus rhythm—fail to capture this phenomenon.
Purpose
We developed a novel Holter-derived parameter, the ventricular cycle-to-cycle variation (VCC), quantifying ventricular irregularity during AF. We aimed to evaluate its prognostic significance in the setting of HFpEF.
Methods
We prospectively screened, between November 2023 and July 2025, patients who underwent 24-hour Holter monitoring after hospitalization for acute heart failure in a single hospital. Those with HFpEF and permanent AF were included in this analysis. HFpEF was defined by LVEF ≥50% and supporting clinical, echocardiographic, or biomarker criteria. The primary endpoint was rehospitalization for heart failure (HF-rH). VCC (%) represented the absolute percentage variation between two consecutive RR intervals. Cox proportional hazards models estimated the association between VCC markers and HF-rH, with a priori adjustment for age, sex, coronary artery disease, COPD, and serum creatinine level.
Results
Sixty patients (mean age 81.5 ± 9.3 years; 55% women; mean LVEF 60.3 ± 6.5%) were included. Over a median follow-up of 303 days (IQR 192–431), 20 (33.3%) were rehospitalized for heart failure. Mean VCC was higher in the HF-rH group (21.9 ± 5.6% vs 18.6 ± 4.2%, p < 0.01). In multivariable analysis, mean VCC remained independently associated with HF-rH (aHR 2.2, 95% CI 1.21–4.01, p = 0.01). A threshold of 21.3% best discriminated patients at risk, with VCC >21.3% associated with a markedly higher risk of rehospitalization (HR 5.43, 95% CI 2.07–14.25, p < 0.001).
Conclusions
In HFpEF patients with permanent AF, increased beat-to-beat ventricular irregularity—quantified by the VCC index—was associated with heart failure rehospitalization. This novel index may represent a new marker and potential therapeutic target in HFpEF patients. Our results need to be confirmed in larger population.Example of VCC (%) computationFreedom from HF-rH