Zero-burden atrial fibrillation: does stroke risk diminish the longer a person is free from atrial fibrillation?

Two considerations guide the decision to prescribe oral anticoagulation (OAC) in atrial fibrillation (AF). First is the cumulative risk for stroke or systemic embolism (SSE) based on the CHA2DS2-VASc score.1 The second is whether or not AF is a clearly reversible occurrence secondary to a modifiable cause. Most agree that for the patient with an annual risk for SSE >1%, indefinite OAC is indicated.2 The trials that led to the approval of non-vitamin K antagonist oral anticoagulants, have hinted at different stroke risks based on AF burden and may allow for a pathway for involving this factor in the decision to safely discontinue anticoagulation. One unanswered question is the possibility of discontinuing OAC in patients without AF recurrences. While there are sub-populations of AF patients with defined OAC requirements, such as patients requiring cardioversion or those with mechanical valves, the role of long-term OAC is less clear in patients who have post-operative AF, those with cardiac implantable electronic device (CIED) detected AF, and those who have had an ablation.2 A single recommendation does not fit all patient groups. We believe that the group of patients who can stop OAC safely needs further study.