Abstract Aims Optimal management of oral anticoagulation (OAC) after atrial fibrillation (AF) ablation remains uncertain. We evaluated thromboembolic and bleeding outcomes associated with OAC discontinuation vs. continuation at a clinically relevant 6-month post-ablation landmark. Methods and results This target trial emulation used data from a multicentre prospective registry in China. Patients with CHA2DS2-VA scores ≥2, no prior thromboembolism, and no atrial arrhythmia recurrence within 6 months after ablation were classified according to OAC discontinuation or continuation at the 6-month landmark. The primary outcome was the composite of stroke, systemic embolism, and major bleeding. Inverse probability weighting was applied, with intention-to-treat as the primary analysis. Among 8339 patients (mean age 68 years; 40.5% women), 4406 discontinued and 3933 continued OAC. The risk of the primary outcome did not differ significantly between groups [weighted hazard ratio (HR) 0.93; 95% CI 0.67–1.29]. Thromboembolic risk was similarly comparable (HR 0.96; 95% CI 0.69–1.35). Clinically relevant non-major bleeding occurred less frequently after OAC discontinuation (HR 0.68; 95% CI 0.47–0.97). Findings were consistent in sensitivity analyses. Annualized thromboembolic rates after discontinuation were <1% in patients with CHA2DS2-VA scores 2–3 but 1.52% in those with scores ≥4. Conclusion Among patients without prior thromboembolism who remained arrhythmia-free at 6 months after AF ablation, OAC discontinuation was not associated with a difference in the composite outcome of stroke, systemic embolism and major bleeding compared with OAC continuation. Residual risk remained low in patients with CHA2DS2-VA scores 2–3 but exceeded conventional thresholds in those with scores ≥4.
Xiaodong Peng, Liu He, Jue Wang et al.· Europace· 0 citations
BACKGROUND
Despite the growing use of catheter ablation for atrial fibrillation, large-scale studies assessing the efficacy and safety of oral anticoagulation (OAC) after ablation, particularly in patients with high stroke risk, remain limited.
METHODS
This prospective study enrolled consecutive patients from the China-AF (China Atrial Fibrillation) registry between August 2011 and June 2022. Stroke risk was stratified by CHA2DS2-VA score as low (0-1), intermediate (2), or high (≥3). The study end points were thromboembolism (ischemic stroke or systemic embolism), and bleeding (International Society on Thrombosis and Hemostasis major bleeding and clinically relevant non-major bleeding). A 6-month landmark analysis was applied to evaluate the association of OAC with end points using incidence rates and Cox models.
RESULTS
Among 13 669 patients (median follow-up, 4.0 years), 2637 continued and 11 032 discontinued OAC at the 6-month landmark. OAC was not associated with reduced thromboembolism risk across low- (adjusted hazard ratio [aHR], 1.11 [95% CI, 0.70-1.77]; P=0.649), intermediate- (aHR, 0.64 [95% CI, 0.36-1.16]; P=0.141) or high-stroke risk patients (aHR, 1.05 [95% CI, 0.74-1.48]; P=0.801). In contrast, continued OAC was associated with higher bleeding risk, including clinically relevant non-major bleeding across stroke risk strata, and International Society on Thrombosis and Hemostasis major bleeding among high-risk patients (aHR, 2.32 [95% CI, 1.19-4.50]; P=0.013). These results were consistent across subgroups and sensitivity analyses.
CONCLUSIONS
In this large, real-world cohort of patients with atrial fibrillation undergoing catheter ablation, continued OAC was not associated with lower thromboembolic risk, but with higher major bleeding risk among patients with CHA2DS2-VA scores ≥3. These findings support individualized post-ablation anticoagulation strategies and warrant future investigation.
REGISTRATION
URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06987825.
Lan Ren, Xiaodong Peng, Sitong Li et al.· Journal of the American Hear...· 0 citations
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