Oral anticoagulation discontinuation after atrial fibrillation ablation: a systematic review and meta-analysis of randomized trials

Abstract

AIMS: The need for long-term oral anticoagulation (OAC) after apparently successful atrial fibrillation (AF) catheter ablation remains uncertain. Although ablation reduces AF recurrence, it is unclear whether this translates into a low stroke risk to sufficiently discontinue anticoagulation. This systematic review assesses whether stopping OAC after successful AF ablation affects thromboembolic or bleeding risk. METHODS AND RESULTS: We searched MEDLINE, Embase, and Scopus up to 13 November 2025 for randomized controlled trials (RCTs) enrolling adults with AF who underwent catheter ablation and were subsequently randomized to continue or discontinue OAC. Outcomes were pooled using random-effects models. The primary endpoints were stroke, systemic embolism, and major bleeding. Three RCTs met inclusion criteria (n = 2324). Participants remained arrhythmia-free for at least 6 months before randomization and had mean CHA(2)DS(2)VASc score range of 2.0-2.6. Over a median follow-up of 25.14 months (IQR 17.44-30.57), discontinuing OAC did not increase stroke risk [OAC 0.86% vs. no OAC 0.69%; risk difference (RD) 0.24%; 95% confidence interval (CI) -0.67% to 1.15%; P = 0.61]. No systemic embolic events occurred in either group. Annualized stroke incidence was similarly low between groups (incidence rate ratio 1.32; 95% CI 0.32-5.41; P = 0.70). Continuing OAC significantly increased major bleeding (OAC 0.90% vs. no OAC 0.34%; RD 0.91%; 95% CI 0.17-1.65%; P = 0.02). CONCLUSION: In patients who remain arrhythmia-free after AF ablation, stopping OAC did not increase thromboembolic events and substantially reduced major bleeding, suggesting that in post-ablation patients with low thromboembolic risk, and no demonstration of AF relapse for at least 6-12 months, discontinuation of OAC may be potentially safe.