Safety of discontinuing anticoagulation after atrial fibrillation ablation

Abstract

Abstract Background Although there has been substantial evidence to support the use of catheter ablation in rhythm management of patients with atrial fibrillation (AF), the safety of discontinuing anticoagulation post-ablation remains unclear. Purpose This meta-analysis aims to evaluate the safety of discontinuing versus continuing anticoagulation in patients with AF who underwent catheter ablation with successful maintenance of sinus rhythm post-ablation. Methods A literature search was performed using the databases PubMed, Embase, and Web of Science, identifying studies that evaluated the association of anticoagulation, including vitamin-K antagonists (VKA) and direct oral anticoagulants (DOAC), in patients with AF who underwent ablation procedures. Clinical endpoints include occurrence of cerebrovascular accident (CVA) and major bleeding events. Randomized controlled trials and retrospective cohort studies were primary sources of literature. The search was not restricted to time or publication status. Results A total of 18,947 patients with AF who underwent catheter ablation met the inclusion criteria. 5,508 patients continued anticoagulation, and 13,439 patients had their anticoagulant discontinued in the follow-up period. Studies included both patients with paroxysmal and persistent atrial fibrillation. Studies required patients to complete at least eight weeks of anticoagulation after ablation prior to discontinuation. The average CHADSVASc score was 2.2 (Range 1.1 – 4.1), average age was 63 years old, and 63.7% were men. The anticoagulation group received either VKA or DOACs. Mean follow up was 31.4 months (Range 21.6 – 45.6 months). There was no statistically significant difference in risk of acute CVA in the follow up period in patients who discontinued anticoagulation compared to patients who continued anticoagulation (OR 1.49, 95% CI 0.71-3.14, p=0.29). However, continuation of anticoagulation after AF ablation was associated with a significantly increased risk of major bleeding events (OR 3.9, 95% CI 2.34, 6.49; p0.01). This increased bleeding risk was seen in studies involving patients on unspecified anticoagulation with either VKA or DOACs and in studies exclusively involving patients who were treated with DOACs. Conclusions Discontinuation of anticoagulation does not appear to be associated with increased risk of CVA in AF patients who undergo successful catheter ablation and is associated with lower risk of major bleeding events on long-term follow-up. Additional high-quality studies with extended follow-up time and extended monitoring for recurrent AF are required to further characterize when providers may safely consider discontinuing anticoagulation in the appropriate patient populations. This meta-analysis marks a key step towards addressing this question.Figure 1 Figure 2