November 21, 2013

DynaMed EBM Journal Volume 8, Issue 47

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: November 21, 2013

Expiration Date: November 21, 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: 1304159C


Last week 750 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 274 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," a collection of articles related to statin use was selected by the DynaMed Editorial Team.

New ACC/AHA Guidelines for Statins/Calculator Overestimates Risk/DynaMed Provides Patient-Specific Benefit Estimation
References: Circulation 2013 Nov 12 early online PDF, Lancet 2013 Nov 19 early online PDF (level 2 [mid-level] evidence)

Last week the American College of Cardiology/American Heart Association (ACC/AHA) published guidelines on cardiovascular risk assessment, and lifestyle changes and cholesterol-lowering treatment to reduce cardiovascular risk (J Am Coll Cardiol 2013 Nov 12 early online PDF, Circulation 2013 Nov 12 early online PDF). Many DynaMed topics have been updated to incorporate these new guidelines and replace the 2002 National Cholesterol Education Program (NCEP) guidelines. For the Statins for prevention of cardiovascular disease topic 3 major issues are of exceptional interest.

1. The ACC/AHA guidelines do not identify “target” cholesterol levels as the goal when treating dyslipidemia.

This is now consistent with guidelines from other countries (such as 2008 NICE guidelines in the United Kingdom) which recognize benefit in treatment from overall risk reduction but not specific benefit from treating to target levels. The ACC/AHA guidelines (unlike the NICE guidelines) recommend monitoring cholesterol levels on treatment, especially for the purpose of monitoring and encouraging treatment adherence.

2. The threshold for when statin therapy is recommended are much lower in the ACC/AHA guidelines than in the NICE guidelines.

The ACC/AHA guidelines recommend treatment with a 10-year risk for cardiovascular disease events > 7.5% and suggest treatment may be reasonable at a risk of 5%-7.5%, while NICE recommends statins therapy for adults with a 10-year risk > 20%. Both groups recommend statin therapy for most patients with diabetes or established cardiovascular disease.

3. Use of Pooled Cohort Equations is proposed for estimating the 10-year risk of cardiovascular disease events.

The Pooled Cohort Equations appear to overestimate cardiovascular risk. This was found in comparison to actual event rates in the 2 cohorts used for independent external validation of these equations, and was also reported in 3 large primary prevention cohorts (Lancet 2013 Nov 19 early online PDF). The DynaMed topic on Cardiovascular risk prediction includes multiple approaches for risk estimation, including links for their use and evidence supporting them.

To put this into perspective for patients:

To understand the benefits for an individual patient it is useful to estimate the absolute benefit of treatment for that patient. This can be understood as the number of patients who would need to be treated for 5 years to prevent one adverse outcome (NNT). We made estimates of the NNT for selected major adverse outcomes at different levels of predicted 10-year risk, using estimates for risk reductions derived from systematic reviews:

NNT for Statins for 5 Years:
10-year risk of CVD events 5-year NNT for CVD events 5-year NNT for myocardial infarction 5-year NNT for stroke 5-year NNT for mortality
5% 160 278 910 *
7.5% 108 186 606 *
10% 80 140 456 *
15% 54 94 304 334
20% 40 70 228 250

Abbreviations: CVD, cardiovascular disease; NNT, number needed to treat (to prevent 1 outcome)

* no apparent mortality reduction in lowest-risk patients (BMJ 2013 Oct 22;347:f6123)

Courtesty: DynaMed

The guidelines consider risks for adverse effects to be minimal. Randomized controlled data find low rates of serious adverse events, such as rate of myopathy 1 per 10,000 person-years, and a modest increase in diabetes (NNH 255 over 4 years [Lancet 2010 Feb 27;375(9716):735]) Observational studies have reported up to 17.4% rates of statin-related adverse events (Ann Intern Med 2013 Apr 2;158(7):526)

For more information, see the Statins for prevention of cardiovascular disease topic in DynaMed.

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

DynaMed Events

American Society of Hematology (ASH), December 7-10, 2013
Representatives will be attending the ASH conference, held at the Ernest N. Morial Convention Center in New Orleans, Louisiana. Stop by booth 3907 to discuss peer review, mobile access, and free trial information.

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

If you would like to meet with a DynaMed representative at an event, please contact us at

Call for Peer Reviews

We are currently seeking reviewers for:

ACE inhibitors for heart failure

Aldosterone antagonists for heart failure


DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Cardiology
Deputy Editor of Oncology
Medical Writer
Medical Editor
Associate Editor

Learn more about DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training