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Perioperative Anticoagulation — ABIM Board MCQ

Instant feedback + full explanation. One question, done properly.

HardHematologyPerioperative AnticoagulationABIM Board

A 73‑year‑old patient with nonvalvular atrial fibrillation (CrCl 70 mL/min) on apixaban is scheduled for elective high‑bleeding‑risk abdominal surgery. According to current US guidance, what is the optimal perioperative anticoagulation strategy?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Hold approximately 48 hours before surgery; resume 48–72 hours after surgery once hemostasis is confirmed; no heparin bridging

Option D is correct. Both the FDA labeling for apixaban and the 2025 practical guidance summarizing the PAUSE trial explicitly recommend a ~48‑hour preoperative hold for patients with preserved renal function undergoing high‑bleeding‑risk surgery, with resumption at 48–72 hours postoperatively once hemostasis is established, and no heparin bridging is required. Options A and B maintain anticoagulation too close to surgery, increasing bleeding risk. Option C shortens the hold period inadequately and proposes resumption too early (12 h) before hemostasis. Option E suggests bridging and excessive preoperative interruption, both contrary to guidance and increasing bleeding risk without benefit.

Reference: 2025 practical guidance summarizing PAUSE protocol; FDA apixaban prescribing information (2025).