In patients with atrial fibrillation (AFib), the most feared consequence is not the arrhythmia itself but the associated risk of stroke. Although decision-making tools to assess stroke risk in nonvalvular AFib have become more nuanced, the threshold to recommend oral anticoagulation (OAC) for stroke prevention has become lower over time. This is reflected in the 2023 ACC/AHA/ACCP/HRS guideline for managing AFib, which assigned a class I recommendation for OAC for a CHA₂DS₂-VASc score ≥2 in men and ≥3 in women, and a class IIa recommendation for OAC for a CHA₂DS₂-VASc score of 1 in men and 2 in women. Importantly, use of aspirin and other antiplatelets as an alternative to OAC was deemed harmful (class III recommendation).

Often OAC is prescribed lifelong as AFib is considered a progressive condition without a cure. Although patients can be asymptomatic or minimally symptomatic during the arrhythmia, they are advised to adhere to long-term OAC. Over time, patients tend to become weary of OAC due to bleeding risk, drug interactions, side effects, adherence challenges and cost. For many years, AFib patients with elevated stroke risk had no alternative to long-term OAC and either accepted the associated consequences or accepted the increased risk of stroke if they discontinued it against medical advice. Not surprisingly, AFib patients likened the need for long-term OAC as "managing a necessary evil."¹

An alternative to long-term warfarin use – left atrial appendage occlusion (LAAO) – was approved for these patients in 2025 by the U.S. Food and Drug Administration, guided by the PROTECT-AF and PREVAIL trials that demonstrated noninferiority of LAAO for stroke prevention and significant reductions in long-term bleeding risks. Subsequently, PRAGUE-17 similarly demonstrated noninferiority of LAAO for a composite endpoint of stroke prevention, clinically significant bleeding and cardiovascular death vs. direct oral anticoagulants (DOACs).

Gradually, the threshold has become lower for recommending LAAO in place of long-term OAC. This was also reflected in the 2023 guideline, which assigned a class 2a recommendation for LAAO in patients with a CHA₂DS₂-VASc score ≥2 and a contraindication to long-term OAC due to a nonreversible cause, and a class 2b recommendation for LAAO for a CHA₂DS₂-VASc score ≥2 and a preference to avoid long-term OAC use.

Despite explicit guidelines advocating for anticoagulation or LAAO in well-defined AFib patient populations, real-world practice patterns have been discordant. Indeed, of 647 AFib patients from the PINNACLE Registry deemed appropriate for OAC (CHA₂DS₂-VASc score ≥2), the primary cardiologist or physician concurred on the need for OAC for only 27% in a 2023 study.²

The top reasons cited (not mutually exclusive) for avoiding OAC were patient refusal (39%), low AFib burden or successful rhythm control therapy (33%), fall risk (30%), low perceived risk of stroke (24%) and already receiving aspirin for another condition (23%). A separate 2023 study surveyed 2,000 physicians (500 each of general cardiologists, interventional cardiologists, electrophysiologists and vascular neurologists) and determined the top four reasons for not recommending LAAO included concerns about procedure risks or complications (60%), limited efficacy vs. DOACs (43%), logistical issues related to insurance, billing or reimbursement (33%) and safety vs. DOACs (30%).³

The role of LAAO continues to receive mixed reviews in recent clinical trials. OPTION, presented at AHA 2024, showed that concomitant AFib ablation and LAAO, vs. AFib ablation with continued OAC, was associated with a lower risk of nonprocedure-related major or clinically relevant nonmajor bleeding (8.5% vs. 18.1%, p<0.001) and noninferior for a composite of death from any cause, stroke or systemic embolism (SE) at 36 months.⁴ Notably, patients who underwent concomitant AFib ablation and LAAO were switched from DOAC to low-dose aspirin three months post procedure.

However, CLOSURE-AF, presented at AHA 2025, questioned the safety and efficacy of LAAO vs. DOACs, conflicting with results from PRAGUE-17. CLOSURE-AF randomized 912 AFib patients with elevated stroke risk (CHA₂DS₂-VASc score ≥2) and increased bleeding risk (HAS-BLED score ≥3, history of bleeding or chronic kidney disease) to LAAO or physician-directed standard care (primarily anticoagulation with DOAC).⁵ At a median of three years, standard care was superior to LAAO for the composite endpoint of stroke, SE, cardiovascular/unexplained death or major bleeding (hazard ratio 1.28, 95% CI 1.01-1.62).

Is it possible that successful AFib ablation can reduce stroke risk and obviate the need for long-term OAC and LAAO? Although the 2023 ACC/AHA guideline acknowledged a distinct AFib stage (3D) for patients who have undergone "successful AFib ablation," defined as "freedom from AFib after percutaneous or surgical interventions to eliminate AFib," it stopped short of recommending cessation of OAC after a successful AFib ablation. However, two recent clinical trials, ALONE-AF and OCEAN, have indicated that OAC may not be necessary for stage 3D AFib patients.

Both trials randomized AFib patients with elevated stroke risk who had successful AFib ablation, defined as no atrial arrhythmias >30 sec within one year after ablation.

In ALONE-AF with 840 patients, at two years, the composite endpoint of stroke, SE and major bleeding was significantly lower in the no OAC group vs. the DOAC group (0.3% vs. 2.2%).⁶ This was driven by a significantly higher rate of major bleeding in the OAC group (1.4% vs. 0%). Rates of ischemic stroke or SE did not differ significantly (0.3% vs 0.8%).

Among the 641 patients in OCEAN randomized to rivaroxaban or low-dose aspirin, no significant difference was seen at three years in the composite endpoint of stroke, SE or new covert embolic stroke (0.8% vs 1.4%) or in fatal or major bleeding (1.6% vs 0.6%).⁷

As we begin 2026, the lingering question remains for AFib patients at elevated stroke risk: to anticoagulate or not anticoagulate? The short answer is yes for now, but perhaps not forever as multiple procedural options exist to mitigate long-term stroke risk. If successful AFib ablation can be reasonably achieved, then the duration of OAC can be as short as a year. If concomitant AFib ablation and LAAO can be performed, then the duration of OAC can be as short as three months. If standalone LAAO is performed then OAC could be stopped immediately afterwards, assuming patient tolerance to short-term dual antiplatelet use.

With all these options, the new consideration is no longer if a patient can stop anticoagulation, but when.

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This article was authored by Edward Chu, MD, FACC (@Ed_Chu_MD), an electrophysiology attending physician in Miami, FL.

References

1. Olsson K, Hörnsten Å, Hellström Ängerud K. Treated with preventive anticoagulation therapy in atrial fibrillation: The patients' perspective. Nurs Open. 2022;9(6):2657-64.
2. Cannon CP, Kim JM, Lee JJ, et al., on behalf of the BOAT-AF Investigators and Research Coordinators. Patients and their physician's perspectives about oral anticoagulation in patients with atrial fibrillation not receiving an anticoagulant. JAMA Netw Open. 2023;3;6(4):e239638.
3. Kir D, Van Houten HK, Walvatne KN, et al. Physicians' perspectives on percutaneous left atrial appendage occlusion for patients with atrial fibrillation. Am Heart J. 2023;266:14-24.
4. Wazni OM, Saliba WI, Nair DG, et al., on behalf of the OPTION Trial Investigators. Left atrial appendage closure after ablation for atrial fibrillation. N Engl J Med. 2025;392(13):1277-87.
5. LAAO Doesn't Match Medical Therapy for High-risk AF Patients: Closure AF. Available here. Accessed Jan. 13, 2026.
6. Kim D, Shim J, Choi EK, et al., on behalf of the ALONE-AF Investigators. Long-term anticoagulation discontinuation after catheter ablation for atrial fibrillation: The ALONE-AF randomized clinical trial. JAMA. 2025;334(14):1246-54.
7. Verma A, Birnie DH, Jiang C, et al., on behalf of the OCEAN Investigators. Antithrombotic therapy after successful catheter ablation for atrial fibrillation. N Engl J Med. 2026;394:323-32.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Cardiology Magazine, ACC Publications, CM-Mar-2026, Atrial Fibrillation, Electrophysiology, Anticoagulation Management, Guidelines as Topic, Anticoagulants