Oral Anticoagulation After Atrial Fibrillation Ablation: An Updated Systematic Review and Meta-Analysis of 267 443 Patients.

Abstract

Background: Whether long-term oral anticoagulation (OAC) is necessary after apparently successful atrial fibrillation (AF) ablation remains uncertain. Guidelines recommend continuation based on CHA₂DS₂-VASc score rather than procedural success, yet contemporary evidence, including randomized trials, has produced conflicting results. We aimed to provide an updated and comprehensive assessment of OAC discontinuation following AF ablation.

Methods: We conducted a systematic review and meta-analysis in patients who discontinued versus continued OAC after AF ablation. Outcomes included thromboembolic events (TE) and major bleeding events (MBE). Random-effects models with Hartung-Knapp correction were applied. Heterogeneity, publication bias, influence analyses, subgroup analyses, and risk-of-bias domains were assessed.

Results: In 28 studies (267 443 patients), OAC discontinuation significantly reduced the composite of TE and MBE (RR 0.44, 95% CI 0.32-0.61), driven by a marked decrease in bleeding (RR 0.25, 95% CI 0.16-0.39), without excess thromboembolic risk (RR 0.84, 95% CI 0.64-1.12). Findings remained consistent across subgroup analyses (study design, CHA₂DS₂-VASc, geographic region), with sensitivity and meta-regression confirming robustness and no significant effect modifiers. Funnel plots showed no significant asymmetry for TE, whereas MBE demonstrated evidence of small-study effects.

Conclusions: Discontinuation of OAC after successful AF ablation markedly reduces MBE without a statistically significant increase in TE, highlighting the need for individualized post-ablation anticoagulation strategies. Randomized trials are needed to confirm the safety of tailored oral anticoagulant discontinuation in selected patients, supported by careful long-term follow-up and shared decision-making.