Net clinical benefit of continued oral anticoagulants after successful AF ablation: a nationwide cohort study

Background Current guidelines recommend individual oral anticoagulant (OAC) decision after catheter ablation for atrial fibrillation (AF) based on stroke risk. However, recent randomized trials suggest that OAC discontinuation following successful ablation may be feasible in selected patients. Real-world evidence on the net clinical benefit of continued OAC across thromboembolic risk strata remains limited. Methods Using the Korean National Health Insurance Service database, we identified patients who underwent catheter ablation for AF and remained free of recurrence through 12 months post-procedure (landmark analysis). Patients were classified as OAC continuation (n=2,946) or discontinuation (n=3,771) based on OAC use at the 12-month landmark. Overlap weighting (OW) was applied using a propensity score model with 32 covariates. The primary outcome was a composite of stroke/systemic embolism and major bleeding. Outcomes were analyzed overall and by CHA2DS2-VA subgroup (score 1–2 vs. ≥3). Results After applying overlap weighting using a propensity score model incorporating 32 covariates, adequate balance across all variables was achieved (all standardised mean differences <0.1 after weighting). In the overall OW-adjusted cohort, OAC continuation was associated with significantly higher rates of the primary composite outcome compared with discontinuation (1.34 vs. 0.94 events/100 person-years (PY); HR 1.42, 95% CI 1.12–1.80; P=0.004). This was driven by increased risks of stroke/systemic embolism (0.70 vs. 0.47/100 PY; HR 1.49, 95% CI 1.07–2.07; P=0.018) and major bleeding (0.78 vs. 0.52/100 PY; HR 1.46, 95% CI 1.07–1.99; P=0.016). Among patients with CHA2DS2-VA score 1–2, OAC continuation was associated with substantially higher risks of the composite outcome (1.20 vs. 0.52/100 PY; HR 2.27, 95% CI 1.62–3.18; P <0.001). In contrast, among patients with CHA2DS2-VA score ≥3, no significant difference was observed for any outcome (HR 1.01, 95% CI 0.74–1.39; P=0.946). Conclusion In patients free of AF recurrence at 12 months after catheter ablation, continued OAC was not associated with net clinical benefit, particularly among lower-risk patients (CHA2DS2-VA 1–2). These findings support individualized OAC decision-making guided by thromboembolic risk stratification following successful AF ablation.