Outcomes of Continuing vs Discontinuing Anticoagulation After AFib Ablation: A Meta-Analysis

Background Continuation of oral anticoagulation (OAC) after successful atrial fibrillation (AF) ablation has long been a matter of debate. With the recent publication of randomized controlled trials (RCTs) addressing this question, there is an urgent need for a comprehensive meta-analysis to better clarify the evidence and inform clinical decision-making. Methods A comprehensive search of PubMed/MEDLINE, Embase, Web of Science, and Scopus was performed through November 24, 2025, to identify studies comparing clinical outcomes in patients who continued versus discontinued OAC after AF catheter ablation. Results This meta-analysis included 31 studies (three RCTs, 29 observational studies) comprising 50,327 patients. Overall, continuing OAC after the blanking period was not significantly associated with the risk of stroke/transient ischemic attack (TIA) (odds ratio (OR) = 1.48, 95% CI: 0.84–2.60; P = 0.16), major adverse cardiac event (OR = 0.69, 95% CI: 0.02–22.17; P = 0.69) or all-cause mortality (OR = 1.04, 95% CI: 0.46–2.35; P = 0.92). In contrast, the risk of major bleeding was significantly higher among patients continuing OAC (OR = 4.62, 95% CI: 2.42–8.85; P < 0.01). Subgroup analyses revealed that continuing OAC after the blanking period significantly increased the risk of hemorrhagic stroke (OR = 3.96, 95% CI: 1.10–14.26; P = 0.03), intracranial hemorrhage (OR = 4.62, 95% CI: 1.07–19.89; P = 0.03), and gastrointestinal bleeding (OR = 4.72, 95% CI: 1.62–13.76; P < 0.01). However, continuing OAC was not significantly associated with ischemic stroke (OR = 1.23, 95% CI: 0.56–2.67; P = 0.59) or TIA (OR = 0.50, 95% CI: 0.21–1.16; P = 0.10). Additionally, when stratified by CHA₂DS₂-VASc score, patients with higher scores (≥ 2) had a significantly lower risk of stroke/TIA when continuing OAC after the blanking period (OR = 0.42, 95% CI: 0.18–0.95; P = 0.04). Furthermore, among studies with nonsignificant baseline differences in CHA₂DS₂-VASc scores between on-OAC and off-OAC groups, continuing OAC was associated with a significant protective effect against stroke/TIA Conclusion Continuation of OAC after AF ablation is recommended to be individualized, considering CHA₂DS₂-VASc score, bleeding risk, and other patient-specific factors. Careful risk stratification can help optimize stroke prevention while minimizing major bleeding.