Antithrombotic Management after Successful Catheter Ablation for Atrial Fibrillation: Meta-analysis of the ALONE-AF...

Background and Aims Current guidelines advocate for indefinite direct oral anticoagulant (DOAC) therapy after successful catheter ablation for atrial fibrillation (AF), based on the CHA ₂ DS ₂ -VASc score. This strategy is challenged by the inherent bleeding risk of DOAC versus the potentially reduced stroke risk post-ablation. We aimed to compare long-term antithrombotic strategies in patients with durable freedom from AF recurrence. Methods We conducted a meta-analysis of the ALONE-AF and OCEAN trials enrolling 2124 patients with no documented AF recurrence for ≥1 year after ablation. The trials compared DOAC continuation versus DOAC discontinuation. We calculated pooled risk ratios (RRs) with 95% confidence intervals (CIs) for primary efficacy (thromboembolic events/all-cause mortality) and safety (bleeding events) outcomes. Results The meta-analysis found no statistically significant difference between DOAC continuation and DOAC discontinuation for all stroke or systemic embolism (RR 1.36; 95% CI: 0.16-11.38), transient ischemic attack (RR 0.20; 95% CI: 0.03-1.15), myocardial infarction (RR 0.08; 95% CI: 0.00-1.37), and all-cause mortality (RR 1.43; 95% CI: 0.55-3.74). In contrast, DOAC continuation was associated with a significantly higher risk of major bleeding (RR 3.07; 95% CI: 1.05-8.96) and clinically relevant non-major bleeding (RR 2.47; 95% CI: 1.01-6.00). Subgroup analysis confirmed consistent treatment effects. Conclusion In patients who achieve durable freedom from AF recurrence for at least 1 year following catheter ablation, the absolute risk of thromboembolic events was very low. Strategies involving the discontinuation of DOACs were associated with a statistically lower risk of bleeding without significant risk of stroke.