Discontinuation of oral anticoagulants is common after catheter ablation in older patients with atrial fibrillation

Background and Aims Guidelines recommend continuing oral anticoagulation (OAC) after atrial fibrillation (AF) ablation based on stroke risk, yet real-world postprocedural OAC management remains poorly characterized. We aimed to evaluate contemporary patterns of OAC use after AF ablation and identify predictors of OAC discontinuation. Methods Using Medicare claims from 2013—2022, we established a cohort of patients undergoing a first AF ablation and assessed patterns of OAC discontinuation during the subsequent year. We defined OAC discontinuation as a dispensing gap ≥ 60 days. Baseline characteristics were evaluated as predictors of discontinuation using least absolute shrinkage and selection operator Cox regression. Results Among 208,232 AF patients (mean age 74.5, 47% women) undergoing ablation, 58% were taking OAC following ablation, 24% discontinued between 3 -12 months, 8% discontinued within 3 months, and 10% did not use OAC within 3 months. Apixaban was the most commonly used OAC agent, while the use of warfarin declined over time. The overall rate of repeated ablation was 26%. We found that 44% of patients with CHA2DS2-VASc score ≥3 discontinued OAC within 1 year after ablation. Higher CHA2DS2-VASc scores and longer pre-ablation OAC use were associated with lower discontinuation, whereas pre-ablation major bleeding, frailty, and use of warfarin (versus direct OACs) increased the likelihood of discontinuation. Conclusion OAC discontinuation after AF ablation is common, including among patients at elevated stroke risk despite guideline recommendations for continued therapy. More data is needed on the clinical consequences of post-ablation OAC discontinuation.