Assessment of Coronary Artery Disease in Non-Valvular Atrial Fibrillation: Is This Light at the End of the Tunnel?

Non-valvular atrial fibrillation (NVAF) is the most common sustained arrhythmia worldwide, and is associated with significant morbidity and mortality. Increasing life expectancy, coupled with a surge in comorbidity burden, has resulted in a sharp increase in NVAF prevalence over the last three decades. Coronary artery disease (CAD) is an important and clinically relevant risk factor of AF. Concomitant CAD has significant implications for AF management and is a major determinant of the overall outcomes. Shared risk factors, a common pathophysiological basis, and heightened thrombogenesis culminating in cardiovascular adverse events, highlight the close association between the two. The clinical course of AF is worse when associated with CAD, resulting in poor heart rate control, increased propensity to develop stroke and myocardial infarction, increased likelihood of acute presentation with hemodynamic collapse and pulmonary edema, increased bleeding tendencies, and poor response to ablation therapies. Emerging research highlighting the significant role of underlying CAD as an independent predictor of thromboembolic risk has paved the way for the adoption of CAD beyond prior myocardial infarction into the symbol "V" of the CHA2DS2-VASc score. In our opinion, elderly patients aged >65 years with AF, with a history of one or more cardiovascular comorbidities, or evidence of atherosclerosis in other vascular beds should warrant a closer look and a dedicated effort to look for associated CAD. This would allow for a more holistic and comprehensive approach to patients with AF and ultimately help reduce the disease burden and improve the overall outcomes.