Antithrombotic stewardship: whether to stop anticoagulation after atrial fibrillation ablation

Hospital pharmacists increasingly receive questions about oral anticoagulation (OAC) discontinuation in patients with atrial fibrillation (AF) who remain arrhythmia-free after ablation. Two recent trials, ALONE-AF and OCEAN, reported low annual stroke rates in selected post-ablation cohorts, suggesting limited added stroke protection from OAC in this group. Both studies have key limitations: selective low-risk patient populations, insufficient power for thromboembolic events, limited external validity to older AF patients, and methodological concerns including ALONE-AF's fragility index and OCEAN's comparator choice. Before OAC discontinuation is considered, multiple criteria should be met: first-time ablation with documented 12 month arrhythmia-free status, low thromboembolic risk, absence of prior cerebrovascular events and access to intensified rhythm monitoring, acknowledging that no validated monitoring strategy currently exists to guide anticoagulation decisions after ablation.