Can Oral Anticoagulants Be Safely Discontinued Following Atrial Fibrillation Ablation? A Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data

BACKGROUND Ablation procedures are frequently employed to restore sinus rhythm in atrial fibrillation (AF), given the increased stroke risk associated with AF. The decision to discontinue oral anticoagulation (OAC) therapy post-procedure requires careful consideration of stroke and bleeding risks, especially due to the absence of definitive guidelines. OBJECTIVE This meta-analysis aims to evaluate the implications of OAC discontinuation following catheter ablation for AF, focusing on thromboembolic (TE) and bleeding events. METHODS A systematic search was conducted in four databases, for studies comparing OAC discontinuation with maintenance in AF patient's post-ablation. We pooled odds ratios (OR) for binary outcomes with random-effects model and performed sensitivity analyses with hazard ratios (HR) and subgroups based on CHA2DS2-VASc scores, and patients in sinus rhythm. RESULTS Thirty-two studies were included, comprising 271,808 patients, with 88,164 (32.4%) discontinuing OAC. The primary analysis showed no significant differences in TE incidence (OR 0.90; 95% CI: 0.68 to 1.20; p=0.47) or mortality (OR 0.85; 95% CI: 0.67 to 1.08; p=0.19). However, OAC discontinuation was significantly associated with reduced major bleeding events (OR 0.35; p<0.01). For patients with a CHA2DS2-VASc score >2, discontinuing OAC significantly increased TE risk. For those with CHA2DS2-VASc scores 0-2 and in patients sustaining sinus rhythm, the results were consistent with the overall analysis. CONCLUSION Discontinuation of OACs in AF patient's post-ablation did not significantly affect overall TE incidence but a notable reduction in major bleeding events. However, there was a significant increase in TE risk among patients with CHA2DS2-VASc >2 upon discontinuation.