Long-standing persistent atrial fibrillation with low coronary flow reserve is associated with unnecessary coronary angiography

Abstract

Abstract Background/Introduction Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction. Myocardial perfusion imaging (MPI) is well-established for the diagnosis of coronary artery disease (CAD) and risk-stratification in sinus rhythm (SR) patients. Purpose The aim of this study was to determine the impact of AF and coronary flow reserve (CFR) on revascularization in patients undergoing positron emission tomography (PET) MPI. Methods 680 patients without a known history of CAD were included. 226 paroxysmal AF (PAF) and 114 long-standing persistent AF (LSPAF) patients were identified from a single-center prospective PET MPI registry and propensity matched in a 1:1 ratio to SR patients. The main indications for PET MPI were chest pain and dyspnea. Follow-up was obtained for downstream referral for invasive coronary angiography (CAG) and the occurrence of myocardial infarction (MI) or coronary revascularization. Results Compared with PAF, LSPAF patients were older (p=0.011) and more frequently male (p=0.031), with no significant differences in prior medical history and cardiac risk factors. The number of abnormal scans (infarction or ischemia) did not differ significantly between SR and AF, respectively 22.1% and 18.5% (p=0.253). The frequency of downstream CAG was comparable between the groups (p=0.298), with a significantly higher yield of obstructive CAD in the SR group as compared to PAF and LSPAF groups (63% vs 42% vs 36%, p=0.007). A low CFR (defined as CFR below the median of 2.4) in patients with SR showed significantly more revascularization compared with PAF and LSPAF (p<0.001), although more patients with LSPAF and low CFR underwent CAG (p<0.001). In patients with low CFR referred for CAG, the overall prevalence of obstructive coronary artery disease on CAG was 62%, with 30% for LSPAF, 52% for PAF and 78% for SR. There were no significant differences between SR, PAF and LSPAF in the occurrence of MI during a mean follow-up of 36 months (p=0.256). Conclusion A low CFR was only associated with a higher incidence of revascularization in patients with SR. Among patients with low CFR, LSPAF patients have the highest number of unnecessary CAGs as compared with SR and PAF. Funding Acknowledgement Type of funding sources: None.