Net Clinical Benefit of Continuing vs Discontinuing Anticoagulation After Atrial Fibrillation Ablation: Results from a 280,000-Patient Meta-Analysis
In brief
After AF ablation, continuing anticoagulants nearly triples major bleeding without lowering stroke
In a meta-analysis of 280,415 patients, continued anticoagulation after ablation was linked to nearly three times the odds of major bleeding and more than three times the odds of brain bleeding, with no clear reduction in ischemic stroke. The overall balance favored stopping, but randomized trials showed no difference and the findings may not apply to patients at highest stroke risk.
- Journal
- Thrombosis and haemostasis (Q1)
- Published
- 2 November 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Sogol Koolaji, Diana Adrienne Gorog, Joshua H Leader, Vias Markides
- PMID
- 42971252
- DOI
- 10.1055/a-2994-8900
Why clinicians should know about it
- Picked for Epidemiology (paper of the day, 5 November 2026): Meta-analysis of observational cohorts and trials on anticoagulation outcomes
- Picked for Neurology (clinical) (paper of the day, 5 November 2026): Post-ablation anticoagulation evidence directly concerns stroke prevention
Abstract
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.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.