Residual thromboembolic risk and outcomes of oral anticoagulation discontinuation after atrial fibrillation ablation: a target trial emulation

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.

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.

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.