Controversy: Anticoagulants need to be maintained after catheter ablation of atrial fibrillation in patients at risk of stroke—Pro and Contra

Abstract

The pillars of atrial fibrillation (AF) management include stroke prevention, patient-centred symptom directed decisions on rhythm or rate control, and the proactive management of comorbidities and lifestyle changes. These pillars are not in isolation; they are complementary to each other. While oral anticoagulants (OACs) are highly effective for reducing stroke and all-cause mortality in patients with AF, these drugs confer a risk of major bleeding, including intracranial bleeding.

Evidence from clinical trials and observational data shows that early rhythm control, especially with catheter ablation, results in a reduction in stroke risk and/or the reduction in AF burden. The question arises therefore, whether in patients with intermediate or low stroke risk after successful catheter ablation, whether or not to continue or discontinue OAC. Recent randomized trials and observational data have created some debate about whether OAC can be routinely stopped after a successful catheter ablation procedure, without a higher risk of thromboembolism.

In this pro/contra article, we will debate the arguments for and against the cessation of anti-coagulation after catheter ablation, in the context of recent evidence from clinical trials, observational data, and meta-analysis.