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

Release Date: December 17, 2014
Expiration Date: December 17, 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: 1405237F2

Last week 724 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 201 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.

For Patients with Drug-Eluting Stents, Extending Duration of Dual Antiplatelet Therapy from 12 to 30 Months May Decrease the Risk of Stent Thrombosis and Myocardial Infarction, but May Increase the Risk of Major Bleeding and Might Increase Noncardiovascular Mortality

Reference: DAPT trial (N Engl J Med 2014 Dec 4;371(23):2155) (level 2 [mid-level] evidence)

Dual antiplatelet therapy is recommended for at least 12 months in patients having a percutaneous coronary intervention with a drug-eluting stent to reduce the risk of restenosis (Circulation 2011 Dec 6;124(23):e574-651). Extending the duration of DAPT may decrease the risk of stent thrombosis, but evidence on the efficacy of DAPT for > 1 year has been inconsistent (Am J Cardiol 2014 Jul 15;114(2):236, Am J Cardiol 2013 Feb 15;111(4):486). A recent randomized trial compared 12 vs. 30 months of treatment with thienopyridine (clopidogrel or prasugrel) plus aspirin (DAPT) in 9,961 patients (mean age 62 years, 75% male) having drug-eluting stent implantation.

All patients were treated with DAPT for 12 months before being randomized to a thienopyridine vs. placebo for an additional 18 months while aspirin therapy was continued indefinitely. Only patients adherent to therapy and without major adverse events during the first 12 months were eligible for randomization. Of the eligible patients, 50.9% had at least 1 risk factor for stent thrombosis. Between study months 12 and 30, extended 30-month DAPT was associated with reduced stent thrombosis (0.4% vs. 1.4%, p < 0.001 NNT 100) and reduced major adverse cardiovascular and cerebrovascular events (4.3% vs. 5.9%. p < 0.001 NNT 63) compared to standard 12-month DAPT. Extended 30-month DAPT was not without risks, however, as extended DAPT was associated with increased risk of moderate-to-severe bleeding (2.5% vs. 1.6%, p = 0.001 NNH 111). On further analysis, an increased risk of bleeding was observed for moderate bleeding only, with no significant differences in severe bleeding between groups. All-cause mortality during the 18-month randomization period was 2% in patients with extended DAPT vs. 1.5% with placebo (p = 0.05). Increased risk of stent thrombosis and myocardial infarction were observed for the first 3 months after thienopyridine discontinuation, regardless of treatment duration.

This trial suggests that increasing the duration of DAPT to 30 months after implantation of a drug-eluting stent decreases the risk of stent thrombosis as well as major cardiovascular and cerebrovascular events. Extended DAPT therapy was associated with a small increase in all-cause mortality, but this finding was driven by an increase in cancer-related deaths in patients with a cancer diagnosis before randomization. The difference in all-cause mortality between groups was no longer significant if patients with cancer diagnoses before randomization were excluded from analysis. Concerns have previously been raised about whether prasugrel promotes the development or progression of cancer (Arch Intern Med 2010 Jun 28;170(12):1078). Overall, there appears to be a cardiovascular benefit with extended treatment, but patients with pre-existing cancer may not see an overall benefit.

For more information, see the Antiplatelet and anticoagulant drugs for coronary artery disease 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.

PEMSoft Mobile

Free Trial of PEMSoft Mobile 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 EBSCO Health. 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.

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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