Monday, June 18, 2018

Don’t conflate type 2 MI and NSTEMI!

Confusion remains wide spread despite the publication of this distinction years ago. But now, according to this piece in Circulation, the coding world is finally catching up. ICD 10 now has a code for type 2 MI. Here are some of my take home points:

A type 2 MI is not an acute coronary syndrome.

On initial presentation the distinction is based on clinical circumstances and may occasionally be difficult.

Further investigation usually makes the distinction clear by the end of the hospitalization.

Type 2 MI, though a distinct category, is not a primary single entity in that it is always secondary to something else, one or more of many known conditions. For this reason it is heterogeneous and there are no guidelines for type 2 MI per se. Its treatment always consists of management of the underlying conditions that are altering the myocardial oxygen supply demand balance.

Though ICD 10 now recognizes the distinction, type 2 MI has yet to be excluded from certain performance and regulatory categories for MI due to acute coronary syndrome.

Those who conflate NSTEMI and type 2 MI not only expose their ignorance (or disregard) of the classification and pathophysiology of MI but also risk subjecting patients to inappropriate and potentially harmful treatments. An example is provided in the article.

Sunday, June 17, 2018

Metformin monotherapy versus dual therapy with the addition of a sodium glucose co-transporter 2 inhibitor (SGLT-2)


•Type 2 Diabetes Mellitus (T2DM) is a current global threat.
•Sodium-glucose co-transporter 2 inhibitor is a new approach for T2DM management.
•Combined therapy of SGLT2 inhibitor and metformin is more effective.



Type 2 Diabetes Mellitus (T2DM) is a chronic disorder and its treatment with only metformin often does not provide optimum glycemic control. Addition of sodium glucose cotransporter 2 inhibitor (SGLT2) will improve the glycemic control in patients on metformin alone. In this study, an attempt is made to investigate the combined therapy of SGLT-2 with metformin in managing T2DM in terms of lowering HbA1c and body weight and monotherapy using metformin alone in HbA1c and body weight reduction.


To compare the clinical effectiveness of combined therapy using SGLT2 inhibitor and metformin with monotherapy using metformin alone in HbA1c and body weight reduction.


A systematic review of the randomized controlled trials has been carried out and Cochrane risk of bias tool was used for the quality assessment. Patient, Intervention, Comparison and Outcomes (PICO) technique is used to select the relevant articles to meet the objective.


The studies used in this article are multicenter, double-blinded randomized controlled trials on SGLT2 inhibitors with methformin, there were a total of 3897 participants, with a range of 182 to 1186 individual study size were included. Studies showed that combined therapy were more effective in HbA1c and body weight reduction as compared to monotherapy.

Saturday, June 16, 2018

Possible health benefits of dietary magnesium

Friday, June 15, 2018

Methamphetamine related heart failure: rising prevalence, distinct phenotype

Hypothesis: We hypothesized that in a VA population over a 15 year period, we would observe a rising prevalence of MethHF in admitted patients, along with a unique phenotype.

Methods: Among 9588 patients with diagnosis of heart failure treated at San Diego VA Medical Center in between 2005-2015, 480 were identified to have history of methamphetamine abuse as determined by ICD-9 diagnosis code and/or urine toxicology screen as well as a diagnosis code of heart failure. Demographic, diagnostic, and clinical characteristics of MethHF and heart failure patients without methamphetamine use (HF) were compared. ..

Results: From 2005-2015, the prevalence of methamphetamine usage among patients with heart failure increased linearly (Figure 1). A preliminary cohort comparison demonstrated MethHF had similar ejection fraction and BNP levels but trends toward increased troponin levels, more atrial fibrillation, and a higher GFR. MethHF patients had a greater risk of ER visits (2.3 per year vs 0.5 per year, p=0.01) and a trend towards a greater risk of all-cause hospital readmission...

Thursday, June 14, 2018

Metformin use and the risk of B 12 deficiency


Long-term metformin therapy is significantly associated with lower serum vitamin B12 concentration, yet those at risk are often not monitored for B12 deficiency. Because metformin is first line therapy for type 2 diabetes, clinical decision support should be considered to promote serum B12 monitoring among long-term metformin users for timely identification of the potential need for B12 replacement.

Wednesday, June 13, 2018

Metacognition: from study habits to clinical reasoning

This article was published in a pharmaceutical education journal but it has general applicability.

Tuesday, June 12, 2018

High risk medication administration in hospitalized elderly patients preceded falls


Of 328 falls, 62% occurred in individuals administered at least one high-risk medication within the 24 hours before the fall, with 16% of the falls involving individuals receiving two, and another 16% in individuals receiving three or more. High-risk medications were often administered at higher-than-recommended geriatric daily doses, in particular benzodiazepines and BRAs, for which the dose was higher than recommended in 29 of 51 cases (57%). Hospital EMR default doses were higher than recommended for 41% (12/29) of medications examined.


High-risk medications were administered to older fallers. Doses administered and EMR default doses were often higher than recommended. Decreasing EMR default doses for individuals aged 65 and older and warnings about the cumulative numbers of high-risk medications prescribed per person may be simple interventions that could decrease inpatient falls.

It would appear that EMR decision support contributed to the problem.