Stopping or continuing OAC therapy after catheter ablation for AF?

In the ALONE-AF trial among patients without documented atrial arrhythmia recurrence after catheter ablation for AF, discontinuation of OAC therapy reduced the risk of the composite outcome of stroke, systemic embolism or major bleeding compared with continuation of DOAC therapy.

This summary is based on the publication of Kim D, Shim J, Choi E, et al. - Long-Term Anticoagulation Discontinuation After Catheter Ablation for Atrial Fibrillation: The ALONE-AF Randomized Clinical Trial. JAMA. 2025 Oct 14;334(14):1246-1254. doi: 10.1001/jama.2025.14679.

Introduction and methods

Background

Current guidelines recommend continued oral anticoagulant (OAC) therapy after catheter ablation for AF in patients at elevated risk of thromboembolism [1-3], despite limited randomized evidence. Whether long-term OAC can be safely discontinued in patients without recurrent atrial arrhythmias after ablation remains uncertain.

Aim of the study

The aim of the study was to evaluate whether discontinuing OAC therapy is superior to continuing DOAC therapy in patients without documented AF recurrence for at least 1 year after AF catheter ablation.

Methods

The ALONE-AF (Anticoagulation One year after Ablation of Atrial Fibrillation in Patients with Atrial Fibrillation) trial was an open-label, multicenter, RCT conducted at 18 hospitals in South Korea. A total of 840 adults (mean age 64 years; 25% women) with AF, an intermediate to high risk of stroke (defined as a CHA2DS2-VASc score of 1 for men and 2 for women), and no atrial arrhythmia recurrence for ≥1 year after ablation were randomized to discontinue OAC therapy (n=417) or continue DOAC therapy (n=423). In the DOAC group, 78% were prescribed 5 mg of apixaban, 8.7% were prescribed 15 mg of rivaroxaban and 7.3% were prescribed 20 mg of rivaroxaban.

Outcomes

The primary outcome was a composite of stroke, systemic embolism or major bleeding at 2 years.

Main results

• At 2 years, the primary composite outcome occurred in 0.3% of patients in the discontinuation group versus 2.2% of patients in the DOAC continuation group (absolute difference: -1.9 percentage points; 95%CI: -3.5 to -0.3; P=0.02).
• This benefit was primarily driven by fewer major bleeding events (0% vs. 1.4%; absolute difference: -1.4 percentage points; 95%CI: -2.6 to -0.2).
• Ischemic stroke or systemic embolism occurred in 0.3% of patients in the discontinuation group and in 0.8% of patients in the DOAC continuation group (absolute difference: -0.5 percentage points; 95%CI: -1.6 to 0.6).

Conclusion

Among patients without documented atrial arrhythmia recurrence after AF catheter ablation, discontinuation of DOAC therapy reduced the risk of the composite outcome of stroke, systemic embolism or major bleeding compared with continued anticoagulation. This benefit was primarily driven by fewer major bleeding events.

Find this article online at JAMA

References

1. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR. 0000000000001193
2. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414. doi:10.1093/eurheartj/ehae176 
3. Tzeis S, Gerstenfeld EP, Kalman J, et al. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. EP Europace. 2024;26(4):euae043. doi:10.1093/europace/euae043