Discontinuation of Oral Anticoagulants After Successful Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis

The optimal duration of oral anticoagulation (OAC) after successful atrial fibrillation (AF) ablation remains uncertain. We performed an updated meta-analysis comparing postablation OAC continuation (ON-OAC) versus discontinuation (OFF-OAC). A systematic search of MEDLINE, Scopus, and Cochrane CENTRAL was performed from inception until March 2026. We included randomized controlled trials and cohort studies evaluating patients receiving ≥3 months of OAC after AF ablation. Primary outcome was thromboembolism; secondary outcomes were major bleeding, all-cause mortality, and AF recurrence. Random-effect models pooled the effect estimates. Twenty-nine studies (n = 153,352) were included. OFF-OAC did not significantly alter thromboembolism risk [odds ratio (OR): 0.91; 95% confidence interval (CI), 0.64-1.30; P = 0.60], all-cause mortality (OR: 0.67; 95% CI, 0.44-1.02; P = 0.06), or AF recurrence. OFF-OAC significantly reduced major bleeding risk (OR: 0.34; 95% CI, 0.23-0.49; P < 0.00001). Subgroup analysis showed significant effect modification by OAC type, region, and antiplatelet switch. Discontinuation of warfarin (OR: 0.13; 95% CI, 0.05-0.39) or warfarin/nonvitamin K antagonist oral anticoagulants (OR: 0.43; 95% CI, 0.31-0.61) reduced major bleeding (P = 0.04). Greater bleeding risk reduction was observed in non-Asian cohorts (OR: 0.12; 95% CI, 0.04-0.35) versus Asian (OR: 0.45; 95% CI, 0.31-0.64; P = 0.02). Patients switched to antiplatelet therapy also showed lower bleeding risk (OR: 0.18; 95% CI, 0.08-0.39) compared with those not switched (OR: 0.44; 95% CI, 0.28-0.71; P = 0.05). Discontinuation of OAC after AF ablation significantly reduces major bleeding without increasing thromboembolic or mortality risk in appropriately selected patients. Individualized risk stratification is essential to guide postablation anticoagulation decisions.