Discontinuation of anticoagulation therapy after atrial fibrillation ablation: the ALONE-AF and OCEAN studies

Two randomized trials, the ALONE-AF and OCEAN, have provided valuable evidence to guide the management of oral anticoagulation therapy after ablation of atrial fibrillation. In the ALONE-AF study, amongst patients with no documented atrial fibrillation recurrence at 1 year after transcatheter ablation, the 2-year incidence of the composite endpoint of stroke, systemic embolism, and major bleeding was significantly lower in those who discontinued oral anticoagulation compared with those who continued therapy. This difference was driven by a reduction in major bleeding events, with similar rates of stroke between groups. In the OCEAN study, amongst patients without atrial fibrillation (AF) recurrence during the year following transcatheter ablation, rivaroxaban 15 mg, compared with acetylsalicylic acid (ASA), did not significantly reduce the 3-year incidence of stroke, systemic embolism, or new silent embolic cerebral infarction, but was associated with an increased risk of clinically relevant non-major bleeding. The annualized incidence of thromboembolic events was low (0.3-0.6 events per 100 patient-years). Taken together, data from these two trials suggest that discontinuation of oral anticoagulation (OAC) may be a clinically reasonable option in patients without AF recurrence for at least 1 year after ablation. This strategy should be limited to patients at low thromboembolic risk, comparable to those enrolled in the two trials. Furthermore, the implementation of optimal and sustainable rhythmmonitoring strategies is essential to support decisions regarding OAC discontinuation after AF ablation.