Reviews
New papers
Safety of discontinuing oral anticoagulation after atrial fibrillation ablation: an updated systematic review and meta-analysis
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 21 August 2026
6
Views
2
Downloads
Authors
Oral anticoagulant (OAC) therapy after atrial fibrillation (AF) ablation is recommended according to thromboembolic risk rather than procedural success alone. However, the clinical balance between residual thromboembolic risk and bleeding risk after OAC discontinuation remains uncertain because randomized controlled trials (RCTs) and observational studies have reported variable estimates. We conducted an updated systematic review and meta-analysis comparing OAC discontinuation with OAC continuation after AF ablation. Online databases were searched from inception to May 2026 for RCTs and observational studies reporting thromboembolic events, major bleeding, or all-cause mortality after post-ablation OAC discontinuation versus continuation. Random-effects Mantel-Haenszel models were used, and estimates were reported as risk ratios (RRs) with corresponding 95% confidence intervals (CIs). Thirty-two studies comprising 271,808 patients were included, with 88,513 patients discontinuing OAC after ablation. OAC discontinuation, compared with continuation, was not associated with a statistically significant difference in thromboembolic events (RR=0.93; 95%CI=0.72 to 1.20; P=0.58; I²=53%). In contrast, OAC discontinuation significantly reduced major bleeding (RR=0.37; 95%CI=0.27 to 0.52; P<0.00001; I²=60%). No significant effect was observed for all-cause mortality (RR=0.87; 95%CI=0.70 to 1.08; P=0.22; I²=0%). In this updated systematic review and meta-analysis, OAC discontinuation after AF ablation was associated with lower major bleeding without a statistically significant difference in thromboembolic events or all-cause mortality. These findings support individualized, risk-based anticoagulation decisions among selected post-ablation patients rather than routine discontinuation. However, the very low certainty of evidence for thromboembolic outcomes, coupled with a CI that does not exclude potential harm (RR up to 1.20), underscores that these findings should not be interpreted as evidence of safety.
Downloads
Download data is not yet available.
Citations
1. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ Res 2020;127:4-20.
2. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 2014;129:837-47.
3. Chao TF, Potpara TS, Lip GYH. Atrial fibrillation: stroke prevention. Lancet Reg Health Eur 2024;37:100797.
4. Tzeis S, Gerstenfeld EP, Kalman J, et al. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2024;40:1217-354.
5. Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 2019;321:1261-74.
6. Mark DB, Anstrom KJ, Sheng S, et al. Effect of catheter ablation vs medical therapy on quality of life among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 2019;321:1275-85.
7. Turagam MK, Musikantow D, Whang W, et al. Assessment of catheter ablation or antiarrhythmic drugs for first-line therapy of atrial fibrillation: a meta-analysis of randomized clinical trials. JAMA Cardiol 2021;6:697-705.
8. Barra S, Narayanan K, Boveda S, et al. Atrial fibrillation ablation and reduction of stroke events. Stroke 2019;50:2970-6.
9. Rashid AM, Khan MS, Alenezi F, Anker SD, Knebel F. Obesity and left atrial function: state of the art. Global Cardiology 2026;4.
10. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024;149:e1-156.
11. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024;45:3314-414.
12. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest 2010;137:263-72.
13. Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010;138:1093-100.
14. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014;383:955-62.
15. Kim D, Shim J, Choi EK, et al. Long-term anticoagulation discontinuation after catheter ablation for atrial fibrillation: the ALONE-AF randomized clinical trial. JAMA 2025;334:1246-54.
16. Verma A, Birnie DH, Jiang C, et al. Antithrombotic therapy after successful catheter ablation for atrial fibrillation. N Engl J Med 2026;394:323-32.
17. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg 2021;88:105906.
18. Higgins JPT, Thomas J, Chandler J, et al., editors. Cochrane handbook for systematic reviews of interventions. Cochrane; 2024.
19. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898.
20. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919.
21. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.
22. Borenstein M, Hedges LV, Higgins JP, Rothstein HR. A basic introduction to fixed-effect and random-effects models for meta-analysis. Res Synth Methods 2010;1:97-111.
23. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60.
24. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629-34.
25. Schrickel JW, Beiert T, Linhart M, et al. Prevention of cerebral thromboembolism by oral anticoagulation with dabigatran after pulmonary vein isolation for atrial fibrillation: the ODIn-AF trial. Clin Res Cardiol 2024;113:1183-99.
26. Fei ZT, Yao PC, Chen M, et al. Real world risk of discontinuing oral anticoagulation after successful catheter ablation for atrial fibrillation. Heliyon 2024;10:e32516.
27. Hermida A, Zaitouni M, Diouf M, et al. Long-term incidence and predictive factors of thromboembolic events after cryoballoon ablation for atrial fibrillation. Int J Cardiol 2020;321:99-103.
28. Iwawaki T, Yanagisawa S, Inden Y, et al. Discontinuation of oral anticoagulation after successful atrial fibrillation ablation. JAMA Netw Open 2025;8:e251320.
29. Kanaoka K, Nishida T, Iwanaga Y, et al. Oral anticoagulation after atrial fibrillation catheter ablation: benefits and risks. Eur Heart J 2024;45:522-34.
30. Karasoy D, Gislason GH, Hansen J, et al. Oral anticoagulation therapy after radiofrequency ablation of atrial fibrillation and the risk of thromboembolism and serious bleeding: long-term follow-up in a nationwide cohort of Denmark. Eur Heart J 2015;36:307-14a.
31. Lauritzen DJ, Vodstrup HJ, Christensen TD, Hald MO, Christensen R, Heiberg J. Discontinuation of anticoagulants after successful surgical ablation of atrial fibrillation. J Card Surg 2020;35:2216-23.
32. Själander S, Holmqvist F, Smith JG, et al. Assessment of use vs discontinuation of oral anticoagulation after pulmonary vein isolation in patients with atrial fibrillation. JAMA Cardiol 2017;2:146-52.
33. Uhm JS, Won H, Joung B, et al. Safety and efficacy of switching anticoagulation to aspirin three months after successful radiofrequency catheter ablation of atrial fibrillation. Yonsei Med J 2014;55:1238-45.
34. Yang WY, Du X, Jiang C, et al. The safety of discontinuation of oral anticoagulation therapy after apparently successful atrial fibrillation ablation: a report from the Chinese Atrial Fibrillation Registry study. Europace 2020;22:90-9.
35. Arai M, Okumura Y, Nagashima K, et al. Adverse clinical events during long-term follow-up after catheter ablation of atrial fibrillation. Int Heart J 2019;60:812-21.
36. Gallo C, Battaglia A, Anselmino M, et al. Long-term events following atrial fibrillation rate control or transcatheter ablation: a multicenter observational study. J Cardiovasc Med (Hagerstown) 2016;17:187-93.
37. Kochhäuser S, Alipour P, Haig-Carter T, et al. Risk of stroke and recurrence after AF ablation in patients with an initial event-free period of 12 months. J Cardiovasc Electrophysiol 2017;28:273-9.
38. Liang JJ, Elafros MA, Mullen MT, et al. Anticoagulation use and clinical outcomes after catheter ablation in patients with persistent and longstanding persistent atrial fibrillation. J Cardiovasc Electrophysiol 2018;29:823-32.
39. Nakano T, Oka T, Okayama K, et al. Association between oral anticoagulant continuation on thromboembolism and bleeding events in patients with CHADS2 score 0-2 points after catheter ablation for persistent atrial fibrillation. J Cardiol 2025;86:359-65.
40. Oda Y, Nogami A, Komatsu Y, et al. Assessment of long-term use versus discontinuation of direct oral anticoagulant after catheter ablation for atrial fibrillation: RYOUMA Registry subanalysis. Ann Noninvasive Electrocardiol 2025;30:e70067.
41. Okumura Y, Nagashima K, Arai M, et al. Current status and clinical outcomes of oral anticoagulant discontinuation after ablation for atrial fibrillation in Japan: findings from the AF Frontier Ablation Registry. Circ J 2019;83:2418-27.
42. Riley MP, Zado E, Hutchinson MD, et al. Risk of stroke or transient ischemic attack after atrial fibrillation ablation with oral anticoagulant use guided by ECG monitoring and pulse assessment. J Cardiovasc Electrophysiol 2014;25:591-6.
43. Saad EB, d'Avila A, Costa IP, et al. Very low risk of thromboembolic events in patients undergoing successful catheter ablation of atrial fibrillation with a CHADS2 score ≤3: a long-term outcome study. Circ Arrhythm Electrophysiol 2011;4:615-21.
44. Themistoclakis S, Corrado A, Marchlinski FE, et al. The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. J Am Coll Cardiol 2010;55:735-43.
45. Bunch TJ, Crandall BG, Weiss JP, et al. Warfarin is not needed in low-risk patients following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2009;20:988-93.
46. Guiot A, Jongnarangsin K, Chugh A, et al. Anticoagulant therapy and risk of cerebrovascular events after catheter ablation of atrial fibrillation in the elderly. J Cardiovasc Electrophysiol 2012;23:36-43.
47. Hunter RJ, McCready J, Diab I, et al. Maintenance of sinus rhythm with an ablation strategy in patients with atrial fibrillation is associated with a lower risk of stroke and death. Heart 2012;98:48-53.
48. Hussein AA, Saliba WI, Martin DO, et al. Natural history and long-term outcomes of ablated atrial fibrillation. Circ Arrhythm Electrophysiol 2011;4:271-8.
49. Inoue K, Hirao K, Kumagai K, et al. Long-term efficacy and safety of anticoagulation after atrial fibrillation ablation: data from the JACRE registry. J Cardiol 2021;77:263-70.
50. Nademanee K, Schwab MC, Kosar EM, et al. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J Am Coll Cardiol 2008;51:843-9.
51. Oral H, Chugh A, Ozaydin M, et al. Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 2006;114:759-65.
52. Winkle RA, Mead RH, Engel G, Kong MH, Patrawala RA. Discontinuing anticoagulation following successful atrial fibrillation ablation in patients with prior strokes. J Interv Card Electrophysiol 2013;38:147-53.
53. Yagishita A, Takahashi Y, Takahashi A, et al. Incidence of late thromboembolic events after catheter ablation of atrial fibrillation. Circ J 2011;75:2343-9.
54. Yu R, Xi H, Lu J, et al. Real-world investigation on discontinuation of oral anticoagulation after paroxysmal atrial fibrillation catheter ablation in China. Ann Palliat Med 2020;9:940-6.
55. Proietti R, AlTurki A, Di Biase L, et al. Anticoagulation after catheter ablation of atrial fibrillation: an unnecessary evil? A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2019;30:468-78.
56. Romero J, Cerrud-Rodriguez RC, Diaz JC, et al. Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: a systematic review and meta-analysis. J Cardiovasc Electrophysiol 2019;30:1250-7.
57. Liu XH, Xu Q, Luo T, Zhang L, Liu HJ. Discontinuation of oral anticoagulation therapy after successful atrial fibrillation ablation: a systematic review and meta-analysis of prospective studies. PLoS One 2021;16:e0253709.
58. Wang X, Li M, Wang X, Zhang Z. It can be safe to discontinue oral anticoagulants after successful atrial fibrillation ablation: a systematic review and meta-analysis of cohort studies. Medicine (Baltimore) 2023;102:e35518.
59. Noseworthy PA, Yao X, Deshmukh AJ, et al. Patterns of anticoagulation use and cardioembolic risk after catheter ablation for atrial fibrillation. J Am Heart Assoc 2015;4:e002597.
60. Ahmed M, Muskan F, Zaheer M, et al. Safety and efficacy of left atrial appendage closure in cancer versus non-cancer patients: a systematic review and meta-analysis. Global Cardiology 2025;3:82-8.
61. Waqas SA, Khan TM, Siddiqi AK, et al. The impact of frailty on in-hospital outcomes in patients with HFrEF. Global Cardiol 2025;3:213-20.
62. Usman MS, Hamid A, Qazi SU, et al. The effect of SGLT2 inhibitors on health status in patients with heart failure: a systematic review and meta-analysis. Global Cardiol 2024;2:88-97.
63. Chopra V, Khan MS, Abdelhamid M, et al. iCARDIO Alliance global implementation guidelines on heart failure 2025. Global Cardiol 2025;3:47-74.
64. Anker SD, Ji L, Kindel T, et al. iCARDIO Alliance global implementation guidelines for the management of obesity 2025 - Focus on prevention and treatment of cardiometabolic disease. Global Cardiol 2025;3:181-206.
65. Chen LY, Chung MK, Allen LA, et al. Atrial fibrillation burden: moving beyond atrial fibrillation as a binary entity: a scientific statement from the American Heart Association. Circulation 2018;137:e623-44.
66. Goette A, Kalman JM, Aguinaga L, et al. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace 2016;18:1455-90.
67. Kamel H, Bartz TM, Elkind MS, et al. Atrial Cardiopathy and the risk of ischemic stroke in the CHS (Cardiovascular Health Study). Stroke 2018;49:980-6.
68. Thompson SG, Higgins JP. How should meta-regression analyses be undertaken and interpreted? Stat Med 2002;21:1559-73.
69. ClinicalTrials.gov. Discontinuation of Anticoagulations After Successful Catheter Ablation of Atrial Fibrillation: DESTINATION: National Library of Medicine (US); 2026 [Available from: https://clinicaltrials.gov/study/NCT06615596.
70. ClinicalTrials.gov. Discontinuation of Anticoagulation With Intensive Rhythm Monitoring in Post-ablation Patients With Atrial Fibrillation: DIAMOND-AF Bethesda (MD): National Library of Medicine (US); 2026 [Available from: https://clinicaltrials.gov/study/NCT06871228.
71. ClinicalTrials.gov. Pill-in-the-POCKET Oral Anticoagulation Strategy After AF Catheter Ablation: POCKET-OAC Bethesda (MD): National Library of Medicine (US); 2026 [Available from: https://clinicaltrials.gov/study/NCT06216769.
How to Cite
1.
Cheema AAA, Cheema AA, Shahab A, Sohail S, Mithani A, Ayub MT, et al. Safety of discontinuing oral anticoagulation after atrial fibrillation ablation: an updated systematic review and meta-analysis. Global Cardiol [Internet]. 2026 Aug. 21 [cited 2026 Aug. 22];. Available from: https://www.globalcardiology.info/site/article/view/115
Copyright (c) 2026 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
