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Current guidelines recommend indefinite anticoagulation after ablation of atrial fibrillation (AF) in patients with a CHA2DS2-VASc score ≥2–3, but few data support this practice. In a recent randomized trial (ALONE-AF), stopping anticoagulation 1 year after ablation did not raise stroke risk; now, another trial (OCEAN) has examined the same issue.
Researchers randomized 1300 patients with successful catheter ablation (no AF at 1 year clinically or on Holter monitoring) to receive rivaroxaban 15 mg or low-dose aspirin. Exclusion criteria included severe renal disease, hypercoagulability, and age >85. The mean CHA2DS2-VASc score was 2.2; only 10% of patients had scores ≥4.
At 3 years, the incidence of the composite outcome (stroke, systemic embolism, or new covert stroke on MRI) did not differ significantly between treatment groups (0.8% with rivaroxaban and 1.4% with aspirin).
Major bleeding occurred slightly more often with rivaroxaban than with aspirin (1.6% and 0.6%), but this did not reach significance.
Verma A, et al. Antithrombotic therapy after successful catheter ablation for atrial fibrillation. N Engl J Med 2025 Nov 8; [e-pub] 10.1056/NEJMoa2509688.41211931
Comment
This trial, along with ALONE-AF, supports discontinuing anticoagulation in patients with no recurrence after ablation. I’m still somewhat concerned about patients with CHA2DS2-VASc scores ≥4, but this study provides reassurance that stopping anticoagulation is reasonable for most patients.
Readers may wonder about aspirin as the comparator in this study; the authors chose it because older studies showed that it had a modest stroke-reduction effect in patients with AF and very high stroke risk. But in this postablation population, it essentially functioned as placebo, and I wouldn’t recommend it after successful ablation unless a patient had other cardiovascular indications for it.