Net Clinical Benefit of Continuing vs Discontinuing Anticoagulation After Atrial Fibrillation Ablation: Results from a 280,000-Patient Meta-Analysis

Background Oral anticoagulation (OAC) in patients with atrial fibrillation (AF) reduces ischaemic stroke (IS), but increases bleeding, including intracranial haemorrhage (ICH). As catheter ablation reduces AF burden and IS risk, we evaluated the net clinical benefit (NCB) of continuing versus discontinuing OAC after AF ablation. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies comparing OAC continuation versus discontinuation after AF ablation. NCB was calculated as the reduction in IS with continued OAC minus 1.5 × the increase in ICH. Results Thirty-eight studies were included (3 RCTs, 35 cohort studies), enrolling 280,415 patients, with 2.7 years' follow-up. In RCTs, there was no difference between patients on-OAC vs. off-OAC for IS, major bleeding, ICH, or NCB. In cohort studies, IS was similar, but major bleeding (OR, 3.02; 95%CI, 2.06-4.42, p<0.001) and ICH (OR, 3.65; 95%CI, 2.31-5.77, p<0.001) increased, with net clinical harm (NCB -0.46; 95% CI, -0.82 to -0.10, p=0.012). Combining all studies, IS was similar, but major bleeding (OR, 2.93; 95% CI, 2.08-4.14, p<0.001) and ICH (OR, 3.63; 95% CI, 2.34-5.63, p<0.001) were increased with continued OAC, with NCB favouring discontinuation (NCB -0.46; 95% CI, -0.77 to -0.14, p=0.004). Conclusion The benefit of OAC thromboprophylaxis is attenuated after AF ablation but contributes to bleeding, supporting consideration of OAC discontinuation post-ablation. However, this cannot be extrapolated to the highest ischaemic risk patients and, as risks are dynamic and sinus rhythm maintenance is not guaranteed, close surveillance would be essential if considering this approach.