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Periprocedural DOAC management — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Periprocedural DOAC managementUSMLE Step 3

A man taking apixaban for atrial fibrillation undergoes elective pancreatic surgery after an appropriate preoperative interruption. Hemostasis is secure, oral intake is possible, and thromboembolic risk is not extreme. When should therapeutic apixaban generally be resumed after this high-bleeding-risk operation?

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Correct answer: D — Resume therapeutic apixaban approximately 48–72 hours after surgery

The best answer is “Resume therapeutic apixaban approximately 48–72 hours after surgery”. CHEST perioperative guidance uses procedure bleeding risk to time DOAC resumption; high-bleeding-risk surgery generally warrants about 48–72 hours before therapeutic resumption when hemostasis is secure. Routine therapeutic heparin bridging is not required for a DOAC.

Reference: CHEST Guideline: Perioperative Management of Antithrombotic Therapy: https://journal.chestnet.org/article/S0012-3692%2822%2901359-9/fulltext