The feasibility and the prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance (CMR) in patients with atrial fibrillation (AF) is unknown, because most studies have excluded arrhythmic patients.

The aim of our study was to assess the feasibility and the prognostic value of vasodilator stress perfusion CMR in patients with AF.

Between 2008 and 2018, we prospectively included consecutive patients with AF referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or non-fatal myocardial infarction. The diagnosis of AF was confirmed on 12-lead ECG before and after CMR, and patients with sinus rhythm during CMR were excluded. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE).

Of 639 patients with AF and suspected or stable chronic CAD (72±9 years, 77% men), 602 (94%) completed the CMR protocol, and among those 538 (89%) completed the follow-up [median follow-up 5.1 (3.3–7.1) years]. Reasons for failure to complete CMR included AF-related ECG-gating problems (n=17), intolerance to stress agent, renal failure, declining participation and claustrophobia. Stress CMR was well tolerated without severe adverse event. Using Kaplan–Meier analysis, the presence of myocardial ischemia identified the occurrence of MACE [hazard ratio (HR): 7.56; 95% confidence interval CI: 4.86–11.80; P<0.001]. In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischemia was an independent predictor of a higher incidence of MACE (HR: 5.88; 95% CI: 3.70–10.07; P<0.001) (Fig. 1).

Stress CMR is technically feasible and has a good discriminative prognostic value to predict the occurrence of MACE in patients with AF.