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Objectives: Atherosclerosis is an established risk factor for atrial fibrillation (AF). While evaluation for coronary artery disease (CAD) is routinely performed in patients with AF and left ventricular systolic dysfunction (LVSD), patients with preserved LV contractility are not routinely screened. Echocardiographic evidence of atherosclerosis (aortic valve sclerosis, papillary muscle fibrosis or calcification, mitral annular calcification, and ascending aorta thickening or calcification) has been shown to predict clinical CAD.Methods: We investigated prevalence of subclinical atherosclerosis by echocardiography in 77 consecutive patients (32% females, 63+/-9.7 years old, 5% active smokers, 18.2% with LV ejection fraction (EF) <50%, 66% with hypertension, 13% with diabetes, 2.6% with chronic kidney disease, and 1 patient with peripheral artery disease) referred for AF ablation.Results: Majority of patients referred for AF ablation manifested significant echocardiographic evidence of atherosclerosis: 62% increased aortic thickening or calcification, 55% aortic valve sclerosis, 42% papillary muscle fibrosis or calcification, and 39% mitral annular calcification. Despite high prevalence of atherosclerosis, only 19% of patients with preserved LVEF (>50%) underwent pre-ablation non-invasive assessment for ischemia. Abnormal stress tests were uncommon (5% of tested patients), but were significantly increased in patients with LVSD (20% vs. 7% in patients with EF >50%). In 10 patients with LVSD, who underwent cardiac catheterization, non-obstructive CAD was noted in 5 (50%) and additional 2 (20%) had obstructive CAD/underwent PCI. In 14 patients with preserved LVEF who underwent cardiac catheterization, non-obstructive CAD was noted in 2 (14.3%) while 4 (28.6%) had obstructive CAD (all 6 had echocardiographic evidence of atherosclerosis).Conclusions: Systemic and coronary atherosclerosis are common in patients referred for AF ablation, with significant proportion suffering from obstructive CAD. Our findings highlight importance of evaluation for ischemia in patients referred for AF ablation with LVSD or evidence of atherosclerosis on non-invasive imaging.