The cognitive implications of oral anticoagulant (OAC) discontinuation after successful atrial fibrillation (AF) ablation remain uncertain. A randomized analysis from the ALONE-AF trial, published in Heart Rhythm, assessed whether stopping OAC therapy was associated with cognitive decline in patients without AF recurrence. Eligible participants were aged 19–80 years, had no atrial arrhythmia recurrence for at least 12 months after catheter ablation, and had at least 1 non-sex-related stroke risk factor defined by the CHA₂DS₂-VASc score.

Patients were randomized in a 1:1 ratio to discontinue or continue OAC therapy. This analysis included a subset of 646 participants (318 no-OAC; 328 OAC) who completed the Montreal Cognitive Assessment (MoCA) at baseline and at 2-year follow-up.

The mean age was 63.9 years, 25.9% were women, and the median CHA₂DS₂-VASc score was 2 (interquartile range, 1–3). Over 2 years, the mean total MoCA scores improved in both groups. In the no-OAC group, scores increased from 24.4 to 25.0 (mean difference, 0.6; 95% confidence interval [CI], 0.3–0.9), while scores in the OAC group increased from 24.2 to 24.9 (mean difference, 0.7; 95% CI, 0.4–1.0).

Between-group comparison showed no significant difference in cognitive change (difference, 0.1; 95% CI, −0.3 to 0.5; P=0.759). No significant differences were identified across individual cognitive domains.

OAC discontinuation may not be associated with measurable cognitive decline over 2 years in this analysis. Findings should be interpreted cautiously because the study was not designed to formally evaluate this association.