Cessation of oral anticoagulation after atrial fibrillation ablation: who and when?

PURPOSE OF REVIEW: The ideal long-term oral anticoagulation (OAC) management strategy for patients who have undergone successful catheter-based atrial fibrillation ablation is not well defined. Over the past 20 years, observational studies suggested that OAC could be safely discontinued for patients with intermediate thromboembolic risk, but randomized trial data were lacking to inform clinical practice. RECENT FINDINGS: Recently, two randomized clinical trials on this topic have been published: The Optimal Anticoagulation for Enhanced Risk Patients Post-Catheter Ablation for Atrial Fibrillation (OCEAN) and Anticoagulation One Year after Ablation of Atrial Fibrillation in Patients with Atrial Fibrillation (ALONE-AF). These trials showed that OAC cessation at 1 year after successful atrial fibrillation ablation was not associated with increased thromboembolic risk for patients with an intermediate stroke risk profile (i.e. CHA2DS2-VASc 1-3 points). In both trials, the annualized rate of thromboembolism was below 1%. Patients with higher thromboembolic risk (i.e. CHA2DS2-VASc ≥4 points or history of stroke/transient ischemic attack) were minimally represented in these trials. SUMMARY: For patients without high-risk features for thromboembolism, the OCEAN and ALONE-AF trials showed that OAC cessation is a viable option at 1 year after ablation if no atrial fibrillation is documented by routine rhythm monitoring modalities.