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Direct oral anticoagulant follow-up — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Direct oral anticoagulant follow-upUSMLE Step 3

A 72-year-old with atrial fibrillation and CHA₂DS₂-VASc score 4 takes full-dose apixaban. A drug-eluting coronary stent was placed 3 years ago. He has had no recurrent ischemia, acute coronary syndrome, or stent thrombosis, and bleeding risk has increased after a gastrointestinal hemorrhage. Which chronic antithrombotic regimen is preferred?

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

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Correct answer: D — Continue apixaban alone and discontinue routine antiplatelet therapy

The best answer is “Continue apixaban alone and discontinue routine antiplatelet therapy”. Beyond 1 year after coronary revascularization, an atrial-fibrillation patient without recurrent ischemia or prior stent thrombosis should generally receive oral-anticoagulant monotherapy. Continuing either aspirin or clopidogrel adds bleeding risk, dual antiplatelet therapy does not provide adequate atrial-fibrillation stroke prevention, and vascular-dose rivaroxaban is not the atrial-fibrillation dose.

Reference: 2023 ACC/AHA/ACCP/HRS Guideline for Atrial Fibrillation—Key Perspectives: https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2023/11/27/19/46/2023-acc-guideline-for-af-gl-af