Is Echocardiography Valid and Reproducible in Patients With Atrial Fibrillation?

A Systematic Review

Dipak Kotecha; Mohamed Mohamed; Eduard Shantsila; Bogdan A. Popescu; Richard P. Steeds


Europace. 2017;19(9):1427-1438. 

In This Article

Abstract and Introduction


Aims Echocardiography is vital in the routine assessment and management of atrial fibrillation (AF). We performed a systematic review of the validity and reproducibility of echocardiographic left ventricular systolic and diastolic function in AF, and optimal acquisition methods.

Methods and results Online databases were searched for studies in patients with AF at the time of echocardiography (1960 to August 2015), prospectively registered with PROSPERO (CRD42015025297). The systematic review included 32 studies from 3 066 search results (1 968 patients with AF). Average age was 67 years, 33% were women, mean LVEF 53% (±10%), and average E/e' 11.7 (±2.7). Data on the validity and reproducibility of systolic indices were extremely limited. In contrast, diastolic parameters demonstrated correlation with invasive filling pressure and adequate reproducibility: E/e' (n = 444) r = 0.47 to 0.79; IVRT (n = 177) r = –0.70 to –0.95; E/Vp` (n = 55) r = 0.63 and 0.65; pulmonary vein diastolic flow (n = 67) r = –0.80 and –0.91. Elevated E/e' (>15) was associated with functional capacity, quality of life, and impaired prognosis. For optimal acquisition in AF patients, cardiac cycles with controlled heart rate (<100 beats/min) and similar preceding and pre-preceding RR intervals are required. Cardiac cycle length and equivalence were more important than the number of beats averaged.

Conclusion With careful selection of appropriate cardiac cycles, echocardiography is a valid tool to identify diastolic dysfunction in AF, and E/e' is an independent marker of clinical status and adverse prognosis. However, data on systolic function was extremely limited and requires further prospective study and assessment of variability in clinical practice.


Atrial fibrillation (AF) is an increasingly common heart rhythm disturbance that leads to frequent hospital admissions, heart failure, stroke, and higher mortality.[1] There is a close relationship between AF and heart failure, with numerous risk factors common to both conditions, and shared pathophysiology in patients with both reduced[2] and preserved[3] left ventricular ejection fraction (LVEF). Depending on the type of AF, the rate of prevalent heart failure is between 33% and 56%;[4] hence clinicians treating patients with AF need reliable information on both systolic and diastolic left ventricular (LV) function. Echocardiography is the primary tool used in clinical practice and provides vital guidance to determine appropriate use of anticoagulation, rate-control therapy, and rhythm-control strategies, as well as important information on co-existing or precipitating pathology and prognostic data.[5] All of these important clinical decisions require echocardiographic measures that are valid and reproducible, regardless of cardiac rhythm.

The loss of synchronized atrial contraction and altered left atrial pressure is likely to affect the reproducibility of echocardiographic measurements in AF. Factors that have been implicated include the ratio of preceding to pre-preceding cycle length and heart rate during image acquisition. Both of these influence the volume of ejection and consequently the results of the most commonly-used measurements of LV function, particularly where these are taken over a number of cardiac cycles. Joint guidelines published by the American Society of Echocardiography and the European Association of Cardiovascular Imaging suggest a minimum of five beats in AF patients, although this is based on consensus opinion.[6] For diastolic function, the British Society of Echocardiography recommends averaging over 5–10 beats during cycle lengths equivalent to a heart rate between 60–80 beats/min.

We performed a systematic and focused review of published literature on the use of echocardiography for determination of systolic and diastolic LV function in patients with AF. Our main objectives were to assess the validity of echocardiographic measures whilst in AF, both against other modalities and clinical outcomes, and the reproducibility of these parameters. A further objective was to appraise the acquisition of images. This includes the optimal number of repeated measurements and cardiac cycle lengths that would reduce variability of systolic and diastolic evaluation and allow confidence in the echocardiographic diagnosis of systolic or diastolic dysfunction in AF.