Anticoagulation discontinuation after atrial fibrillation ablation: A systematic review and meta-analysis of randomized and observational evidence

Background Whether oral anticoagulation (OAC) can be discontinued after successful atrial fibrillation (AF) ablation remains uncertain. Guidelines recommend continuing OAC based on CHA 2 DS 2 -VASc rather than post-ablation rhythm. Emerging data has renewed interest in selective OAC discontinuation strategies. Objective To synthesize randomized and observational evidence comparing continuation versus discontinuation of OAC after AF ablation. Methods MEDLINE and Embase were searched from inception through November-2025 for studies comparing continuation versus discontinuation of OAC after the post-ablation blanking period. Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment. Random-effects meta-analysis was conducted. Prespecified subgroup analyses were performed by study design and post-ablation antithrombotic strategy. Leave-one-out sensitivity analyses assessed robustness. Results Ten studies (3 randomized trials and 7 observational) including 242,083 participants were analyzed. Discontinuation of OAC after AF ablation was not associated with an increased risk of thromboembolic events compared with continued anticoagulation (risk ratio [RR] 0.93; 95% CI 0.86–1.02; I 2 =0%). Randomized trials showed concordant but imprecise estimates (RR 1.06; 95% CI 0.23–4.86). OAC discontinuation was associated with significantly lower major bleeding (RR 0.38; 95% CI 0.22–0.68) and intracranial hemorrhage (RR 0.23; 95% CI 0.10–0.53). Lower risks of ischemic stroke and all-cause mortality were observed in pooled analyses, although these findings were driven primarily by observational cohorts and should be interpreted cautiously. Conclusion Among patients undergoing AF ablation, discontinuation of OAC was associated with substantially lower bleeding risk without an observed increase in thromboembolic events. Because the available evidence is dominated by observational studies and randomized trials remain small, these findings should not be interpreted as proof of thromboembolic safety. Decisions regarding anticoagulation discontinuation should remain individualized pending results of adequately powered randomized trials.