Key result
Continuing OAC after AF ablation yields net harm, driven by ~3-fold higher major bleeding.
Why the study?
Oral anticoagulation in AF reduces ischaemic stroke but increases bleeding, and because catheter ablation reduces AF burden and stroke risk, the net clinical benefit of continuing versus discontinuing OAC after ablation required evaluation.
Does continuing oral anticoagulation improve net clinical benefit compared to discontinuing oral anticoagulation in patients after atrial fibrillation ablation?
Meta-Analysis (n=280,415)
Yes
Does continuing oral anticoagulation improve net clinical benefit compared to discontinuing oral anticoagulation in patients after atrial fibrillation ablation?
In a large meta-analysis of patients post-AF ablation, continuing oral anticoagulation did not reduce ischaemic stroke compared to discontinuation but significantly increased major bleeding and intracranial haemorrhage, resulting in net clinical harm.
Answers are grounded in this paper and cite their sources.
Supports individualized OAC discontinuation post-AF ablation, though should not yet change practice; leaves open the true risk-benefit balance pending larger RCTs given observational study dominance.
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.
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Koolaji et al. (2026) conducted a meta-analysis in Atrial fibrillation after catheter ablation (n=280,415). Continuing oral anticoagulation (OAC) vs. Discontinuing oral anticoagulation (OAC) was evaluated on Net clinical benefit (reduction in ischaemic stroke minus 1.5 x the increase in intracranial haemorrhage) (NCB -0.46, 95% CI -0.77 to -0.14, p=0.004). Continuing OAC after AF ablation increased major bleeding (OR 2.93) and ICH (OR 3.63) without reducing stroke, yielding a net clinical benefit favoring discontinuation (NCB -0.46; P=0.004).
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