July 3, 2013

DynaMed EBM Journal Volume 8, Issue 27

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: July 3, 2013

Expiration Date: July 3, 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

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, 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 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 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: 1304158I


Last week 435 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 266 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.

Intensive Blood Pressure Control Might Not Reduce Death or Major Disability, but May Improve Quality of Life After Acute Intracerebral Hemorrhage
Reference: N Engl J Med 2013 Jun 20;368(25):2355, (level 2 [mid-level] evidence)

Blood pressure is commonly elevated following acute intracerebral hemorrhage. Current guidelines from the American Heart Association suggest “modest reduction” if systolic pressure is > 180 mm Hg (Stroke 2010 Sep;41(9):2108), but the optimal blood pressure target is unclear. The INTERACT2 randomized trial compared intensive blood pressure control to guideline-recommended treatment in 2,839 patients with acute intracerebral hemorrhage.

Patients within 6 hours of onset of intracerebral hemorrhage who had systolic blood pressure 150-220 mm Hg were randomized to 1 of 2 treatment strategies and were followed for 90 days. The intensive blood pressure control strategy targeted a systolic blood pressure of < 140 mm Hg with the goal of reaching the target within 1 hour and then maintaining it for 7 days. Under the guideline-recommended strategy, the target systolic blood pressure was < 180 mm Hg. Agents used for blood pressure control were at the treating physicians’ discretion. All patients received oral antihypertensive drugs or topical nitrates within 7 days. History of hypertension was common (72%), and 45% were already taking antihypertensive drugs. The mean systolic blood pressure attained at 1 hour was 150 mm Hg with intensive control and 164 mm Hg with guideline-recommended treatment (33.4% in intensive control group achieved target systolic pressure at 1 hour).

The primary outcome was a composite of death or major disability (defined as modified Rankin score 3-5). Intensive control was associated with a nonsignificant decrease in the primary outcome (52% vs. 55.6%, p = 0.06), but there was no significant difference in mortality (11.9% vs. 12%). There were also no significant differences in the rates of nonfatal serious adverse events (23.3% vs. 23.6%) or neurologic deterioration in first 24 hours (14.5% vs. 15.1%). However, intensive blood pressure control was associated with improved quality of life outcomes. At 90 days, patients in the intensive control group had significantly lower rates of problems with self-care (46.8% vs. 51.6%, p = 0.02, NNT 21), usual activities (60.8% vs. 66.1%, p = 0.006, NNT 19), and pain and discomfort (39.8% vs. 45%, p = 0.01, NNT 20).

For more information, see the Intracerebral hemorrhage topic in DynaMed.

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

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