Attenuation of the Heartbeat-Evoked Potential in Patients With Atrial Fibrillation

JACC Clin Electrophysiol. 2022 Oct;8(10):1219-1230. doi: 10.1016/j.jacep.2022.06.019. Epub 2022 Aug 31.


Background: The heartbeat-evoked potential (HEP) is a brain response to each heartbeat, which is thought to reflect cardiac signaling to central autonomic areas and suggested to be a marker of internal body awareness (eg, interoception).

Objectives: Because cardiac communication with central autonomic circuits has been shown to be impaired in patients with atrial fibrillation (AF), we hypothesized that HEPs are attenuated in these patients.

Methods: By simultaneous electroencephalography and electrocardiography recordings, HEP was investigated in 56 individuals with persistent AF and 56 control subjects matched for age, sex, and body mass index.

Results: HEP in control subjects was characterized by right frontotemporal negativity peaking around 300 to 550 ms after the R-peak, consistent with previous studies. In comparison with control subjects, HEP amplitudes were attenuated, and HEP amplitude differences remained significant when matching the samples for heart frequency, stroke volume (assessed by echocardiography), systolic blood pressure, and the amplitude of the T-wave. Effect sizes for the group differences were medium to large (Cohen's d between 0.6 and 0.9). EEG source analysis on HEP amplitude differences pointed to a neural representation within the right insular cortex, an area known as a hub for central autonomic control.

Conclusions: The heartbeat-evoked potential is reduced in AF, particularly in the right insula. We speculate that the attenuated HEP in AF may be a marker of impaired heart-brain interactions. Attenuated interoception might furthermore underlie the frequent occurrence of silent AF.

Keywords: atrial fibrillation; echocardiography; electrocardiogram; electrocardiography; electroencephalography; heart-brain connection; heartbeat-evoked potential.

MeSH terms

  • Atrial Fibrillation*
  • Electroencephalography
  • Evoked Potentials / physiology
  • Heart Rate / physiology
  • Humans
  • Interoception* / physiology