Risk factors of atrial arrhythmia recurrence and impact on the benefit of oral anticoagulation discontinuation: insights from the ALONE-AF trial
K Dongseon, D Kim, J Park, I Y Oh, J Kim, P S Yang, J Shim, E K Choi, Y S Lee, J S Ko, K M Park, J H Sung, H W Park, H S Park, B Y JoungAbstract
Background
In the ALONE-AF trial, discontinuation of oral anticoagulation (OAC) reduced the risk of the primary outcome (a composite of stroke, systemic embolism, and major bleeding) in patients without atrial arrhythmia recurrence after catheter ablation for atrial fibrillation (AF).
Purpose
This post-hoc analysis aimed to identify risk factors for atrial arrhythmia recurrence after catheter ablation and to evaluate whether the effect of OAC discontinuation varied according to recurrence risk.
Methods
We randomized patients with AF to continue or discontinue OAC and followed them for ≥2 years. The risk factors associated with atrial arrhythmia recurrence at 2 years were identified using Cox regression models based on backward elimination. We evaluated the 2-year cumulative incidence of the primary outcome using the Kaplan–Meier method and assessed the interaction between recurrence risk and OAC strategy.
Results
Overall, 840 patients (mean age 64.1±8.1 years, 24.9% female) were included. Atrial arrhythmia recurrence was documented in 77 patients and was independently associated with female sex (HR, 2.31 [95% CI, 1.37–3.91]), heart failure (HR, 2.37 [95% CI, 1.35–4.17]), and left atrial enlargement (HR, 1.82 [95% CI, 1.08–3.05]). Among the 231 patients without risk factors, the risk of the primary outcome was significantly higher in patients who continued OAC than in those who discontinued OAC (absolute difference, 5.5% points [95% CI, 1.2–9.7]). Among the 568 patients with ≥1 risk factors, the differences were not prominent (absolute difference, 0.4% points [95% CI, −1.0–1.9]; p for interaction=0.028).
Conclusions
Female sex, heart failure, and left atrial enlargement were identified as risk factors for atrial arrhythmia recurrence. The significant interaction between recurrence-risk strata and OAC strategy supports tailored anticoagulation strategies guided by an individual’s recurrence risk profile.Graphical abstractStudy population