Balancing stroke and bleeding risks: the impact of stopping anticoagulation after aAF ablation - a systematic review and meta-analysis

Catheter ablation has become an effective treatment for atrial fibrillation (AF), potentially reducing the need for continued oral anticoagulant (OAC). However, the optimal anticoagulation strategy post-ablation remains uncertain, particularly in low-risk patients due to inconsistent evidence regarding the balance of thromboembolic and bleeding risks.

We aimed to evaluate the safety and clinical outcomes of OAC discontinuation compared to continuation after AF ablation, with a focus on low-risk patients.

A systematic review and meta-analysis was performed, involving a comprehensive search of PubMed, Embase, and Medline (1990-2024) to identify studies assessing OAC discontinuation after AF ablation (successful ablation at the time of discontinuation). Eligible studies included randomized controlled trials, cohort studies, and observational studies comparing continued versus discontinued OAC. Risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies. Meta-analysis was performed using the Meta package in R with Mantel-Haenszel models, heterogeneity was assessing with I² statistic, and continuity correction where zero events in both groups. Pooled odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for ischemic stroke (IS) and Intracranial haemorrhage (ICH) outcomes reported in studies. Moreover, to compare IS reduction with ICH rise, a weight of 1.5 was given to ICH.

A total of 32 studies were included (1 clinical trial, 17 retrospective, and 14 prospective cohorts), with sample sizes ranging from 106 to 231,374 patients. Most studies did not apply CHA2DS2VASc specific inclusion criteria, except for four studies including only patients with CHA2DS2VASc ≥2. Follow-up durations varied from 1-6 years. The decision to discontinue OAC was guided by physician discretion, thromboembolic risk assessment and adherence to clinical guidelines. Meta-analysis of 16 studies reporting IS found no significant difference in IS between On-OAC and Off-OAC patients (pooled OR: 1.11 [0.72-1.72], I² = 14.2%, p = 0.29). Similarly, in CHA2DS2VASc <2 patients, no significant difference was observed (OR: 1.16 [0.20-6.72]). However, in CHA2DS2VASc ≥2 patients, On-OAC significantly reduced IS risk compared to Off-OAC (OR: 0.25 [0.09-0.64]). Overall, ICH risk was significantly higher in On-OAC patients, with a pooled OR of 5.17 (2.37-11.27). The ratio of total IS to weighted-ICH ORs was <1 in overall and CHA2DS2VASc<2 groups, indicating greater ICH increase than IS reduction in the On-OAC group. This ratio was >1 in CHA2DS2VASc ≥2, but not statistically significant.

Our findings suggest that OAC discontinuation may be considered in selected low-risk patients post-AF ablation, while high-risk patients (CHA2DS2VASc ≥2) may benefit from continued OAC. Further well-designed randomized trials are needed to refine post-ablation anticoagulation strategies.

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