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

Release Date: April 15, 2015
Expiration Date: April 15, 2016

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 providership 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: 1405237W2

Last week 399 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 133 articles were added to DynaMed content.

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

Addition of Folic Acid to Enalapril May Slightly Decrease the Risk of Primary Stroke in Chinese Adults with Hypertension

Reference: CSPPT trial (JAMA 2015 Apr 7;313(13):1325) (level 2 [mid-level] evidence)

Hypertension is a common condition that may begin at age 20-50 years with prevalence increasing with age. An estimated 41% of persons aged 35-70 years have hypertension (JAMA 2013 Sep 4;310(9):959), which is associated with an increased risk of several cardiovascular and cerebrovascular diseases including stroke (Lancet 2010 Jul 10;376(9735):112). Antihypertensive medications are recommended for primary stroke prevention in patients with hypertension (Stroke 2011 Feb;42(2):517), and recent studies have suggested that B vitamin supplementation might also help reduce the risk of primary stroke in high risk patients (Stroke 2010 Jun;41(6):1205, Int J Clin Pract 2012 Jun;66(6):544). A recent randomized trial compared enalapril 10 mg plus folic acid 0.8 mg vs. enalapril 10 mg alone for 5 years in 20,702 Chinese adults aged 45-75 years (mean age 60 years) with hypertension. At enrollment, all patients had resting systolic blood pressure ≥ 140 mm Hg, diastolic blood pressure ≥ 90 mm Hg, or were taking antihypertensive medication. Other antihypertensive medications were used concomitantly during the trial by 57.1% of patients. Patients with a history of stroke, myocardial infarction, heart failure, coronary revascularization, or congenital heart disease were excluded from the trial.

The trial was terminated early after a significant difference between groups in first stroke occurrence exceeding the predefined stopping rule was reached on the fourth interim analysis. Overall treatment adherence was low, with only 69.1% of patients taking ≥ 70% of all study medications and 16.8% of patients not completing the median 4.5 year treatment period. Most patients discontinuing treatment were still followed for outcome events and all randomized patients were including in the primary analysis. Median baseline folate level was 8.1 ng/mL and at last follow-up, the median increase in folate level was 11.2 ng/mL with enalapril plus folic acid vs. 4.4 ng/mL with enalapril alone (no p value reported). There were no significant differences in baseline or follow-up systolic or diastolic blood pressure measurements between groups. Comparing enalapril plus folic acid vs. enalapril alone, first stroke occurred in 2.7% vs. 3.4% (p = 0.003, NNT 141) and ischemic stroke was reported in 2.2% vs. 2.8% (p = 0.002, NNT 167). Enalapril plus folic acid was also associated with a reduction in the composite outcome of stoke, myocardial infarction, or cardiovascular death (3.1% vs. 3.9%, p = 0.002, NNT 125), but there was no significant difference between groups in rates of hemorrhagic stroke, myocardial infarction, cardiovascular death, all-cause death, or adverse events. A subgroup analysis by methylenetetrahydrofolate reductase (MTHFR) gene C677T polymorphisms found no significant differences in rate of first stroke by genotype.

The results of this trial suggest that the addition of folic acid to enalapril may result in a small, but significant decrease in primary stroke incidence among patients with hypertension. Although the magnitude of the reduction was small, adding folic acid to antihypertensive medication may be a cheap and easy way to further reduce the risk of stroke. Its worth considering, however, that baseline folate levels of patients in this study may be lower than in places with folate fortification, thereby limiting the generalizability of this study. Also, although the relative contribution of MTHFR was examined, it is not clear whether the frequency of MTHFR polymorphisms are similar in other populations or if differences in overall population genetics would contribute more substantially to stroke risk.

For more information, see the Prevention of stroke, Vitamin supplementation for cardiovascular disease prevention, and Homocysteine and cardiovascular disease topics in DynaMed.

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Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 9, 2015 Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

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

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