Incidence of thromboembolic events following atrial fibrillation catheter ablation and rate control strategies according to the kind of oral anticoagulation: A systematic review and meta-analysis

Introduction: Anticoagulantion therapy (OAT) represents the cornerstone to reduce thromboembolic events for atrial fibrillation (AF). Recent studies suggest that AF catheter ablation on top of OAT may be useful to further reduce the thromboembolic risk in AF patients. The aim of the present study is to compare the long-term risk of thromboembolic events and treatment-related complications in patients with AF treated by OAT strategies and catheter ablation.

Methods: Pubmed, Cochrane and Google Scholar were searched for studies including >500 patients evaluating AF patients treated with OAT (VKA: vitamin K antagonist or DOAC: Direct oral anticoagulants) and/or AF ablation. Pooled incidence of stroke/year was the primary end point, while that of stroke, of all cause bleeding and of major bleeding the secondary ones. All the analyses were stratified according to the CHADS₂ score of included patients.

Results: Overall, 27 studies were selected, including 50,973 patients in the AF catheter ablation group; 281,595 patients in the VKA group; 54,811 patients in the DOAC group. After a mean follow-up of 2.4 (1.5-3.8) years, the overall incidence of stroke and thromboembolic events was 0.63 per 100 patients/year in AF ablation group, 2.09 per 100 patients/year in VKA group and 1.24 per 100 patients/year in DOAC group (p < 0.001). After stratification in 4 groups according to CHADS₂ score, the incidence of thromboembolic events remained lower in patients included in the AF ablation, followed by DOAC and VKA respectively (p < 0.001), for each CHADS₂ cluster. Both the incidence of all cause bleedings and major bleedings resulted lower in AF ablation group (p < 0.001). The incidence of all-cause mortality in the AF ablation group was significant lower than in the group of OAT (p < 0.0001).

Conclusion: AF catheter ablation significantly reduces the incidence of long-term thromboembolic events compared to both VKA and DOAC. This reduction is maintained in all CHADS₂ score clusters and is strengthened by the concomitant reduction in hemorrhagic complications provided by AF ablation.