April 24, 2013

DynaMed EBM Journal Volume 8, Issue 17

DynaMed Weekly Updates

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: April 24, 2013

Expiration Date: April 24, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1210393H


Last week 593 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 179 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

In Patients Taking Oral Anticoagulants prior to PCI, addition of Clopidogrel (alone) Appears as Effective as Clopidogrel plus Aspirin for Cardiovascular Outcomes and May Reduce Bleeding and Mortality post PCI
Reference: Lancet 2013 Mar 30;381(9872):1107, (level 2 [mid-level] evidence)

Addition of antiplatelet therapy is recommended for prevention of stent thrombosis in patients taking long-term oral anticoagulants who are having percutaneous coronary intervention (PCI) (Eur Heart J 2010 Oct;31(20):2501, Circulation 2006 Jan 3;113(1):156). However, the combination of antiplatelet and anticoagulant therapies may increase bleeding risks, and the optimal antiplatelet regimen for these patients is unclear. A recent unblinded randomized trial compared the efficacy of clopidogrel alone vs. dual antiplatelet therapy with clopidogrel plus aspirin in 573 patients having PCI.

Patients (mean age 70 years) who were taking anticoagulants and having PCI were randomized to clopidogrel 75 mg/day vs. clopidogrel 75 mg/day plus aspirin 80-100 mg/day (dual therapy). Most patients were taking long-term anticoagulants for atrial fibrillation (69%). Other indications included mechanical valves, peripheral arterial disease, pulmonary embolism, and reduced ejection fraction. All patients started clopidogrel 5 days prior to PCI, with a loading dose of 300 mg at least 24 hours (or 600 mg at least 4 hours) before surgery. The allocated antiplatelet therapy was continued for 1 month to 1 year at the discretion of the treating physician in patients with stable coronary disease who received bare metal stents. Clopidogrel was continued for 1 year in patients with acute coronary syndrome or who received drug-eluting stents.

At 1-year follow-up, there were no significant differences in cardiovascular outcomes, including rates of myocardial infarction, stroke, stent thrombosis, and target vessel revascularization. Clopidogrel monotherapy was associated with reductions in bleeding events (19.4% vs. 44.4%, p < 0.0001, NNT 4), blood transfusions (3.9% vs. 9.5%, p = 0.01, NNT 18) and all-cause mortality (2.5% vs. 6.3%, p = 0.027, NNT 27). Cardiovascular mortality was 1.1% with clopidogrel monotherapy and 2.5% with dual antiplatelet therapy (not significant).

For more information, see the Antiplatelet and anticoagulant drugs for elective percutaneous coronary intervention (PCI) topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Extras

DynaMed Resident Focus Newsletter Launches Today

Introducing the DynaMed Resident Focus, a free e-newsletter written by medical residents involved in the DynaMed community. The Resident Focus is an outlet for residents to share recent evidence they find important with their peers, and provides valuable, advertising-free information to clinicians, educators, and trainees who sign up. For participation details, email dynamedcommunity@ebscohost.com. To sign up, click here.

DynaMed Events

Annual Meeting and Exhibition of the Medical Library Association (MLA), May 3-8, 2013
Editor-in-Chief Brian Alper, MD, MSPH, FAAFP, will be presenting at the 2013 Annual Meeting and Exhibition of the Medical Library Association, held at the John B. Hynes Veterans Memorial Convention Center. The topic of the presentation is “The Pace of Change in Practice-Driving Medical Knowledge in New Models of Publishing” and will be presented from 1:30pm to 3:00pm on May 5th. Representatives will be available at the DynaMed booth (216) to discuss peer review, mobile access, and free trial information.

Visit the Medical Library Association website to learn more about the event and for registration information.

Society of Teachers of Family Medicine (STFM) 46th Annual Spring Conference, May 1-5, 2013
Editor-in-Chief Brian Alper, MD, MSPH, FAAFP, will be attending the Society of Teachers of Family Medicine (STFM) 46th Annual Spring Conference, held at the Baltimore Marriott Waterfront Hotel in Baltimore, Maryland. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the Society of Teachers of Family Medicine website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at any of our conferences, please contact us at DynaMedCommunity@ebscohost.com.

Call for Peer Reviews

We are currently seeking reviewers for:

Coronary artery disease (CAD)

Tumor lysis syndrome