Discontinuation of Oral Anticoagulation After Successful Atrial Fibrillation Ablation

The optimal strategy for long-term oral anticoagulation (OAC) after catheter ablation for atrial fibrillation (AF) remains uncertain. Although current guidelines recommend anticoagulation based on thromboembolic risk scores irrespective of rhythm status, this recommendation has not been validated by randomized controlled trials (RCTs). We included 3 RCTs, ODIn-AF (Prevention of Silent Cerebral Thromboembolism by Oral Anticoagulation With Dabigatran After Pulmonary Vein Isolation for Atrial Fibrillation), ALONE-AF (AnticoaguLation ONE Year After Ablation of Atrial Fibrillation in Patients With Atrial Fibrillation), and OCEAN (Optimal Anticoagulation for Higher-Risk Patients Post-Catheter Ablation for Atrial Fibrillation Trial), enrolling patients at least 6 months postablation with no recurrent atrial arrhythmias. Primary efficacy outcomes were all stroke and embolism (including cerebral emboli). The primary safety outcome was major bleeding. Secondary outcomes included clinically relevant nonmajor bleeding and other thromboembolic and bleeding events. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model. In total, 2324 patients were included. Discontinuation of anticoagulation therapy did not significantly increase the risk of all stroke and embolism, at least 6 months postcatheter ablation [RR, 0.58 (0.11-3.12); I2 = 54%]. OAC discontinuation was associated with lower risk of major bleeding [RR, 0.33 (0.11-0.95); I2 = 0%] and clinically relevant nonmajor bleeding [RR, 0.40 (0.19-0.84); I2 = 0%]. No significant differences were observed for other thromboembolic and bleeding events. Sensitivity analyses using per-protocol populations were significant only for a reduction in clinically relevant nonmajor bleeding [RR, 0.33 (0.17-0.65); I2 = 0%]. In patients remaining arrhythmia-free for at least 6 months after AF ablation, discontinuation of OAC was associated with fewer bleeding events without a statistically significant increase in thromboembolic risk. These hypothesis-generating findings highlight the need for larger, well-powered RCTs to better inform postablation anticoagulation strategies.