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

Release Date: November 12, 2014
Expiration Date: November 12, 2015

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: 1405237Z

Last week 475 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 194 articles were added to DynaMed content.

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

A Single Negative Cardiac Troponin Level in Conjunction With Electrocardiogram Data and Clinical Judgment May Safely Rule Out Acute Myocardial Infarction in Patients Presenting to the Emergency Department With Suspected Cardiac Chest Pain
Reference: Emerg Med J 2014 Nov;31(11):872 (level 2 [mid-level] evidence)

Myocardial infarction is a major cause of death and disability worldwide, but identifying myocardial infarction upon presentation to the emergency department can be difficult. Chest pain may result from many widely varying etiologies, ranging from cardiovascular disease to gastrointestinal disease to infection, and many patients with acute coronary syndrome present with atypical symptoms (Resuscitation 2010 Mar;81(3):281). Early exclusion of an acute coronary syndrome in patients presenting to the emergency department could avoid unnecessary and costly hospital admissions, but signs and symptoms alone have not been found to be sufficient to diagnose or rule out acute myocardial infarction (Br J Gen Pract 2008 Feb;58(547):105 and JAMA 2005 Nov 23-30;294(20):2623). A recent study from the United Kingdom investigated the ability of clinical judgment in combination with electrocardiographic (ECG) and cardiac troponin T data to safely rule out acute myocardial infarction in 458 patients (mean age 64 years and 59% men) presenting to the emergency department with suspected cardiac chest pain.

After reviewing ECG results and clinical information, physicians were asked to record their judgment about the likelihood of acute coronary syndrome using a 5-point Likert scale ("definitely not," "probably not," "not sure," "probably," and "definitely"). Physicians did not have access to cardiac troponin levels until after judgments were recorded. Blood samples taken at presentation and ≥ 12 hours after symptom onset were tested for cardiac troponin T and later retested using a high-sensitivity troponin T assay. Using the definition of acute myocardial infarction as a rise or fall of ≥ 20 ng/L in serial cardiac troponin testing with at least 1 measurement above the 99th percentile of the upper reference limit, 17.7% of patients received adjudicated diagnoses of acute myocardial infarction. Clinical judgment alone was insufficient to rule out acute myocardial infarction and safely discharge patients, with negative predictive values between 92% and 97%. By expanding the criteria for discharge to include normal high-sensitivity cardiac troponin levels and no ischemia on ECG in addition to clinical judgment, the negative predictive value increased to 100% (95% CI 95.7%-100%). Using high-sensitivity troponin assay results combined with the ECG and physician assessment of “definitely not”, “probably not”, or “not sure”, 41.7% of patients could be immediately discharged without missing a single acute myocardial infarction. With the use of standard cardiac troponin testing plus ECG and physician assessment of “definitely not” or “probably not” as requirements for discharge, the number of patients that could be safely discharged was 23.1%.

These results show that adding ECG and cardiac troponin T data to the clinical assessment allows physicians to rule out myocardial infarction and safely discharge patients. This study requires further validation, but could significantly reduce hospital admissions without missing any acute myocardial infarctions.

For more information, see the Acute coronary syndrome topics in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Ophthalmology, Orthopedics, and Vascular.

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

PEMSoft Mobile

PEMSoft Now Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCOHealth. Designed by pediatricians, emergency physicians and other medical specialists, the vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices. Visit the PEMSoft page for more information.

DynaMed Contribution Opportunities

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Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.