Optimal Timing for Oral Anticoagulant Discontinuation and Prognosis After Successful Catheter Ablation for Atrial Fibrillation

Background: The optimal timing for discontinuing oral anticoagulants (OACs) after successful atrial fibrillation ablation remains unclear. Objectives: This study sought to assess the adverse events between patients who discontinued OACs and those who continued across various time points following successful ablation to determine the optimal OAC discontinuation timing. Methods: The authors retrospectively analyzed 2,448 patients who underwent initial atrial fibrillation ablation between 2006 and 2022. Thromboembolic and bleeding risks were evaluated across 537 time points of a landmark period (1-537 weeks after ablation) using inverse probability of treatment weighting analysis. Optimal OAC discontinuation timing was defined as the point maximizing the ”reverse” net clinical benefit, calculated as (bleeding risk difference [(intracranial hemorrhage ×1.5) + (non-intracranial hemorrhage ×0.5)]) − thromboembolic risk difference. Results: During a median follow-up period of 34.1 months (Q1-Q3: 12.4-81.9 months), thromboembolic and major bleeding events occurred in 66 (2.7%) (0.63 per 100 patient-years) and 62 patients (2.5%) (0.59 per 100 patient-years), respectively. The estimated thromboembolic risk of OAC discontinuation increased at 4-5 months post ablation, whereas bleeding risk gradually decreased alongside the prolonged discontinuation timing. The reverse net clinical benefit peaked at 8.1 months, suggesting this was the optimal discontinuation timing. At this time point, OAC discontinuation was associated with a high thromboembolic risk (HR: 2.364 P = 0.010) and reduced bleeding risk (HR: 0.176; P = 0.002), with no significant differences in mortality (HR: 0.925; P = 0.830). Conclusions: OAC discontinuation at 8.1 months post ablation may represent the optimal timing for a balance between thromboembolic and bleeding risks in this cohort. Individualized risk assessment facilitates OAC management after successful ablation.