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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: February 4, 2015
Expiration Date: February 4, 2016

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 above.

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; Executive 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 Education Company 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: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. 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(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237M2

Last week 440 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 149 articles were added to DynaMed content.

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

Dabigatran May Increase Risk of Major Bleeding Compared to Warfarin in Older Patients with Atrial Fibrillation

Reference: JAMA Intern Med 2015 Jan 1;175(1):18 (level 2 [mid-level] evidence)

Patients with atrial fibrillation are at increased risk of thromboembolism and oral antithrombotic therapy is therefore recommended for most patients with atrial fibrillation or atrial flutter (Chest 2012 Feb;141(2 Suppl):53S, J Am Coll Cardiol 2014 Dec 2;64(21):e1, Eur Heart J 2012 Nov;33(21):2719). While antithrombotic therapy may decrease the risk of stroke, it also carries an increased risk of bleeding, and physicians and patients must weigh the benefits and risks when selecting an antithrombotic agent. In 2009, the RE-LY trial suggested dabigatran 150 mg could reduce the risk of stroke without increasing the risk of major bleeding compared to warfarin in patients with atrial fibrillation and additional stroke risk factors (N Engl J Med 2009 Sep 17;361(12):1139). Further analysis found a reduction in major bleeding in patients aged < 75 years old that did not extend to patients aged 75 years or older and additional studies found an increased risk of gastrointestinal bleeding with dabigatran (Circulation 2011 May 31;123(21):2363, J Am Geriatr Soc 2014 May;62(5):857, Gastroenterology 2013 Jul;145(1):105, Am J Cardiol 2014 Mar 15;113(6):1066). A recent retrospective cohort study investigated the risk of bleeding in Medicare patients (mean age 76 years) with newly diagnosed atrial fibrillation initiating dabigatran or warfarin oral anticoagulation within 60 days of diagnosis. Dabigatran was prescribed to 1,302 patients with a mean follow-up of 177 days, while 8,102 patients received warfarin with a mean follow-up of 228 days.

Patients were selected from a random cohort of 5% of Medicare beneficiary recipients in 2010 and 2011. Bleeding was categorized as major or minor by 9 anatomical positions with major bleeding including intracranial hemorrhage and hemoperitoneum as well as inpatient or emergency department stays for gastrointestinal, hematuria, or other hemorrhage. A propensity score weighted analysis was performed to balance baseline demographic and clinical characteristics between the dabigatran and warfarin treatment groups. Compared to warfarin, dabigatran was associated with increased risk of overall bleeding (hazard ratio [HR] 1.3, 95% CI 1.2-1.41), major bleeding (HR 1.58, 95% CI 1.36-1.83), and gastrointestinal bleeding (HR 1.85, 95% CI 1.64-2.07). In subgroup analyses, the risk of major bleeding with dabigatran was increased in African American patients compared to white patients, in patients aged 75 years or older compared to patients aged less than 65 years, and in patients with chronic kidney disease. Not all bleeding risk was increased with dabigatran, however, as dabigatran was also associated with a decreased risk of intracranial hemorrhage (HR 0.32, 95% CI 0.2-0.5).

Although previous randomized trials have suggested that dabigatran and warfarin have similar risk of bleeding, this real-world cohort study indicates that dabigatran may be associated with increased risk of overall bleeding and major bleeding compared to warfarin, especially in higher risk populations. The risk of stroke could not be determined in this study due to the short duration of follow-up data available, however the increased risk of bleeding observed suggests that dabigatran should be prescribed with caution in patients with higher risk of bleeding as well as African American patients, patients aged 75 years or older, and patients with chronic kidney disease. Dabigatran may be appropriate for low risk patients and those with an increased risk of intracranial hemorrhage.

For more information, see the topic Thromboembolic prophylaxis in atrial fibrillation topic in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Oncology (especially Breast cancer, Head and neck cancer, Pancreatic cancer), Ophthalmology, Orthopedics, Pediatric Neurology, and Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

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Content in the PEMSoft Mobile app covers more than 3,000 conditions and includes a similar number of medical illustrations, clinical images and videos. PEMSoft Mobile also includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms, and topics covering pediatric injuries and management approaches.

Visit the PEMSoft Mobile App Trial page to access a free trial for both Apple and Android devices.

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