Key result
OAC discontinuation provides an absolute ~5.5-point event reduction in low-risk post-ablation AF.
Why the study?
Although OAC discontinuation reduced adverse events in recurrence-free patients after AF catheter ablation in the ALONE-AF trial, the risk factors for late atrial arrhythmia recurrence and whether the benefit of OAC discontinuation varies by recurrence risk remained to be evaluated.
Does the benefit of oral anticoagulation discontinuation on the composite of stroke, systemic embolism, and major bleeding vary according to atrial arrhythmia recurrence risk in patients without recurrence after catheter ablation for atrial fibrillation?
RCT (n=840)
Randomized
Does the benefit of oral anticoagulation discontinuation on the composite of stroke, systemic embolism, and major bleeding vary according to atrial arrhythmia recurrence risk in patients without recurrence after catheter ablation for atrial fibrillation?
In patients without arrhythmia recurrence after AF ablation, the clinical benefit of discontinuing oral anticoagulation is concentrated in those without recurrence risk factors (female sex, heart failure, left atrial enlargement), supporting a tailored anticoagulation strategy.
Supports OAC discontinuation after AF ablation in low-risk patients without recurrence; extends evidence for risk-stratified anticoagulation strategies.
Background In the ALONE-AF trial, discontinuation of oral anticoagulation (OAC) reduced the risk of the primary outcome (a composite of stroke, systemic embolism, and major bleeding) in patients without atrial arrhythmia recurrence after catheter ablation for atrial fibrillation (AF). Purpose This post-hoc analysis aimed to identify risk factors for atrial arrhythmia recurrence after catheter ablation and to evaluate whether the effect of OAC discontinuation varied according to recurrence risk. Methods We randomized patients with AF to continue or discontinue OAC and followed them for ≥2 years. The risk factors associated with atrial arrhythmia recurrence at 2 years were identified using Cox regression models based on backward elimination. We evaluated the 2-year cumulative incidence of the primary outcome using the Kaplan–Meier method and assessed the interaction between recurrence risk and OAC strategy. Results Overall, 840 patients (mean age 64.1±8.1 years, 24.9% female) were included. Atrial arrhythmia recurrence was documented in 77 patients and was independently associated with female sex (HR, 2.31 [95% CI, 1.37–3.91]), heart failure (HR, 2.37 [95% CI, 1.35–4.17]), and left atrial enlargement (HR, 1.82 [95% CI, 1.08–3.05]). Among the 231 patients without risk factors, the risk of the primary outcome was significantly higher in patients who continued OAC than in those who discontinued OAC (absolute difference, 5.5% points [95% CI, 1.2–9.7]). Among the 568 patients with ≥1 risk factors, the differences were not prominent (absolute difference, 0.4% points [95% CI, −1.0–1.9]; p for interaction=0.028). Conclusions Female sex, heart failure, and left atrial enlargement were identified as risk factors for atrial arrhythmia recurrence. The significant interaction between recurrence-risk strata and OAC strategy supports tailored anticoagulation strategies guided by an individual’s recurrence risk profile.
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Dongseon et al. (2026) conducted an RCT in Atrial fibrillation after catheter ablation (n=840). Oral anticoagulation discontinuation vs. Oral anticoagulation continuation was evaluated on Composite of stroke, systemic embolism, and major bleeding at 2 years (ARR 5.5% points (in patients without risk factors), 95% CI 1.2-9.7, p=0.028 for interaction). Oral anticoagulation discontinuation reduced stroke, systemic embolism, and major bleeding by 5.5% points (95% CI 1.2-9.7) in low-risk AF ablation patients vs 0.4% in high-risk (P_interaction=0.028).
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