October 2, 2013

DynaMed EBM Journal Volume 8, Issue 40

DynaMed Weekly Updates

Quick Links

Join Mailing List



Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: October 2, 2013

Expiration Date: October 2,, 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 Clinical 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: 1210393V


Last week 538 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 260 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.

Multivessel Preventive PCI May Improve Cardiovascular Outcomes Compared to Culprit-Vessel-Only PCI Following STEMI
Reference: PRAMI trial (N Engl J Med 2013 Sep 19;369(12): 1115) (level 2 [mid-level] evidence)

For patients with ST-elevation myocardial infarction (STEMI) having primary percutaneous coronary intervention (PCI), current guidelines from the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) recommend PCI of only the culprit vessel for most patients. Performing PCI in noninfarct arteries at the same time as the infarct artery is discouraged except in cases of hemodynamic compromise (Circulation. 2013 Jan 29;127(4):e362). This recommendation was made due to inconsistent and contradictory data with regard to the efficacy of multivessel PCI mostly from observational studies. Recently, the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) randomized trial compared multivessel PCI vs. culprit-vessel only PCI in 465 patients with STEMI.

Following successful PCI on the culprit vessel, patients were randomized while in the catheterization laboratory to immediate PCI of noninfarct arteries with > 50% stenosis (multivessel PCI) vs. no further PCI procedure. Patients were excluded for previous coronary artery bypass graft (CABG) or for new indication for CABG. Subsequent PCI for angina was recommended only for patients with a confirmed diagnosis of refractory angina (symptoms uncontrolled by medical therapy plus objective evidence of ischemia). Otherwise, any follow-up PCI was discouraged. The primary outcome was a composite of cardiovascular death, nonfatal myocardial infarction, and refractory angina.

The trial was terminated early after an unplanned interim analysis showed a significant reduction in the rate of the primary outcome in the multivessel PCI group. At the time of that analysis, the mean follow-up was 23 months. The primary outcome occurred in 8.8% with multivessel PCI vs. 22.9% with culprit-vessel only PCI (p < 0.001). Multivessel PCI was associated with reduced risks of nonfatal myocardial infarction (3% vs. 8.7% (p = 0.009, NNT 18), refractory angina (5.1% vs. 13%, p = 0.002, NNT 13), and repeat revascularization procedures (6.8% vs. 19.9%, p < 0.001, NNT 8). There was a nonsignificant decrease in cardiovascular mortality with multivessel PCI (1.7% vs. 4.3%, p = 0.07), and no significant difference in noncardiac mortality (3.4% vs. 2.6%).

While the absolute risk difference favoring multivessel intervention was substantial, there were only 74 patients with the primary outcome. The relatively low total number of events in a trial stopped early, especially with an unplanned interim analysis, carries a risk of bias for magnifying the amount of benefit from the intervention.

For more information, see the Revascularization for ST-elevation myocardial infarction (STEMI) topic in DynaMed.

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

DynaMed Events

OMED, September 30 - October 4, 2013
Deputy Editor Tom Hilts, DO, will be attending the OMED conference, held at the Mandalay Bay Hotel and Convention Center in Las Vegas, Nevada. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the OMED website to learn more about the event and for registration information.

ID Week, October 2-6, 2013
Deputy Editor Sheila Mitsuma, MD, will be attending ID Week, held at the Moscone Convention Center in San Fransisco, California. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the ID Week website to learn more about the event and for registration information.

Pediatric Case Study Presentation: Septic Shock, Acute Abdominal Pain, and Suspected Meningococcemia, October 3, 2013
Join Ron Dieckmann, MD, Professor Emeritus of Pediatrics and Medicine at University of California San Francisco and learn how he navigates complicated pediatric clinical presentations. During this 45-minute session, Ron will take an in-depth look at 3 different complex pediatric emergency presentations: septic shock, acute abdominal pain, and suspected meningococcemia

To register select the appropriate time:

  • Thursday, October 3, 2013 at 9 AM PST
  • Thursday, October 3, 2013 at 12 PM PST

    If you would like to meet with a DynaMed representative at an event, please contact us at DynaMedCommunity@ebscohost.com.

    Call for Peer Reviews

    We are currently seeking reviewers for:

    Revascularization for acute coronary syndrome

    Revascularization for coronary artery disease (CAD)