Rivaroxaban Is No Better Than Aspirin After Catheter Ablation for Atrial Fibrillation at Least 1 Year Earlier

In patients who had a successful catheter ablation for atrial fibrillation at least 1 year ago, is there a net benefit to continued anticoagulation?

In patients who had a successful catheter ablation for atrial fibrillation, stopping the anticoagulant after 1 year is safe. (Level of Evidence = 1b)

The researchers identified patients who had undergone a successful catheter ablation procedure for atrial fibrillation at least 1 year ago, with success confirmed by Holter monitoring, including a 48-hour monitoring within 2 months of study enrollment. All patients had a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74, sex [female]) score of 1 or more (men) or 2 or more (women). Groups were balanced at baseline, with a mean age of 66 years, approximately three-fourths had only a single ablation, and two-thirds had paroxysmal atrial fibrillation. Analysis was by intention to treat. Participants were randomized to receive rivaroxaban (Xarelto), 15 mg or low-dose aspirin and were followed up for a median of 3 years. Magnetic resonance imaging was performed at baseline and at the end of follow-up to detect any covert embolic strokes. The trial was stopped early for futility, and the primary outcome of stroke, systemic embolism, or covert stroke occurred in five patients in the rivaroxaban group and nine in the aspirin group (0.8% vs 1.4%; absolute risk difference = 0.6%; 95% CI, −1.8 to 0.5). However, major bleeding occurred numerically more often in the rivaroxaban group (1.6% vs 0.6%; hazard ratio = 2.5; 95% CI, 0.8–8.0). The combination of major bleeds and preventing stroke and embolism makes it a wash. The overall rate of stroke was low and similar to that in people without a history of atrial fibrillation.

Study Design: Randomized controlled trial (single-blinded)

Funding Source: Government, foundation, and industry

Allocation: Concealed

Setting: Outpatient (any)

Reference: Verma A, Birnie DH, Jiang C, et al.; OCEAN Investigators. Antithrombotic therapy after successful catheter ablation for atrial fibrillation. N Engl J Med. 2026;394(4):323-332.

Editor’s Note: Dr. Ebell is cofounder and editor-in-chief of Essential Evidence Plus.