Atrial fibrillation and coronary artery disease: interactions, outcomes and evolving management strategies

Atrial fibrillation (AF) and coronary artery disease (CAD) are prevalent cardiovascular disorders that increasingly coexist as populations age and cardiometabolic comorbidities rise. Their intersection creates a high-risk phenotype, with substantially higher rates of stroke, acute coronary syndromes, heart failure and mortality than either condition alone. This excess risk reflects shared comorbidities and complex bidirectional interactions whereby AF exacerbates myocardial ischaemia and endothelial dysfunction and CAD promotes atrial remodelling and arrhythmogenesis. Despite advances in antithrombotic and rhythm management strategies, care for patients with coexisting AF and CAD remains challenging. Diagnostic evaluation is often obscured by overlapping symptoms and confounding biomarker and imaging findings. Therapeutic decisions require careful integration of ischaemic and arrhythmic risk, particularly when determining antithrombotic intensity, selecting rate or rhythm control and managing ischaemia in AF-related haemodynamics. The evidence base has evolved rapidly, with short- and long-term antithrombotic studies and rhythm-control trials reshaping practice, prompting re-evaluation of management strategies. This Review synthesises current knowledge on epidemiology, pathophysiology and diagnostic challenges of AF-CAD coexistence and provides an updated integrated framework for therapeutic decision-making. We discuss contemporary antithrombotic strategies, rate and rhythm control, ischaemia management and clinical outcomes as well as highlight emerging evidence and practical considerations.