Imagine a world where patients with a successful atrial fibrillation (AF) ablation could potentially stop taking their blood-thinning medications, known as DOACs. This is the intriguing finding from the OCEAN trial, presented at the American Heart Association 2025 Scientific Sessions.
But here’s the catch: This approach may only be feasible for low-risk patients, and the decision-making process remains complex.
The OCEAN trial compared the use of aspirin and the direct oral anticoagulant rivaroxaban (Xarelto) in patients who had undergone successful AF ablation. The results showed no significant difference in the risk of stroke and other adverse outcomes between the two treatment groups over a 36-month follow-up period.
Lead investigator Dr. Atul Verma suggests that patients with a CHA2DS2-VASc score of 1, 2, or even 3 might be able to stop oral anticoagulation after successful ablation. However, he cautions that the trial did not include many patients with recent strokes, so those with a higher CHA2DS2-VASc score due to a recent stroke may require a different approach.
Another study, ALONE-AF, also found that stopping oral anticoagulation after successful AF ablation was associated with better clinical outcomes. This has sparked a debate among experts and physicians, who frequently face the dilemma of whether to continue or discontinue oral anticoagulation in these patients.
And this is where it gets controversial: Current guidelines recommend long-term oral anticoagulation based on stroke risk calculations. However, the OCEAN and ALONE-AF studies provide new evidence that challenges this conventional wisdom.
Dr. Oussama Wazni, an electrophysiologist, agrees that the decision to stop oral anticoagulation is a reasonable consideration for lower-risk patients who maintain normal sinus rhythm. Yet, he emphasizes the difficulty of making such decisions in real-world practice.
So, what does this mean for patients? Well, it’s a bit of a mixed bag. For those who have successfully undergone AF ablation and have a low-to-moderate risk of stroke, the new data suggest they may not need to continue with oral anticoagulation. However, the decision should be made on an individual basis, taking into account each patient’s unique circumstances and risk factors.
The OCEAN trial included over 1,200 patients with a mean age of 66 years. Patients were randomized to receive either aspirin or a modified dose of rivaroxaban, with the data safety and monitoring board recommending the trial’s early termination due to the low likelihood of outcome differences between the two arms.
At three years, the primary composite outcome of stroke, systemic embolism, or new covert embolic stroke occurred in a small percentage of patients in both treatment groups, with no significant difference. The annualized risks were incredibly low, surprising even the investigators.
But here’s another twist: Fatal or major bleeding, the primary safety endpoint, occurred more frequently in the rivaroxaban group compared to the aspirin group. This raises questions about the balance of risks and benefits for each treatment option.
Dr. Michael Ghannam, an electrophysiologist not involved in the study, highlights the importance of the OCEAN trial in addressing a critical clinical question as the prevalence of AF rises with an aging population. While he cautions against using these data to justify widespread discontinuation of anticoagulants, especially in high-risk patients, he acknowledges the low overall event rates post-ablation, which aligns with other randomized trials.
For low-risk patients who have had a successful ablation, Dr. Ghannam advises having serious conversations about discontinuing blood thinners, particularly for those at high risk of bleeding.
Dr. Wazni suggests that physicians hesitant to stop oral anticoagulation could consider using apixaban, as it is associated with less bleeding compared to other DOACs. He also emphasizes the devastating nature of strokes compared to the reversibility of most bleeding events.
In conclusion, the OCEAN trial provides valuable insights into the management of AF patients after successful ablation. While it suggests that stopping DOACs may be feasible for low-risk patients, the decision should be made carefully, considering each patient’s individual risk profile. The debate continues, and further research is needed to guide clinical practice and ensure the best outcomes for patients.