Briggs Blake, Zitelny Edan, Zitelny Tamir
Emergency Medicine, University of Tennessee Medical Center, Knoxville, TN, USA.
Internal Medicine, University of Pennsylvania Department of Medicine, Philadelphia, USA.
Cureus. 2022 Oct 28;14(10):e30816. doi: 10.7759/cureus.30816. eCollection 2022 Oct.
Diabetes mellitus (DM) is a major independent risk factor for cardiovascular disease. Patients who present with the metabolic emergency of diabetic ketoacidosis (DKA) have similar symptoms of diaphoresis, nausea, emesis, and abdominal pain, which can conceal acute coronary syndrome (ACS). We present a unique case where computed tomography (CT) of the abdomen and pelvis with IV contrast played an integral role in diagnosing an acute myocardial infarction in a patient with no typical ischemic symptoms. A 56-year-old female presented to the emergency department with abdominal pain, nausea, and vomiting. She was suspected of having DKA. Aggressive management was started, including weight-based appropriate IV regular insulin. A CT abdomen and pelvis with IV contrast was performed due to persistent abdomen pain. This demonstrated severe hypoattenuation of the posteroinferior aspect of the left ventricular wall. An EKG was immediately performed and was consistent with an inferior STEMI. The patient was taken to the interventional cardiology suite where they found the culprit lesion to be mid-circumflex with 100% stenosis. This case highlights many important lessons in approaching diabetic patients who are presenting with DKA. DM is associated with cardiac autonomic neuropathy (CAN), a condition that greatly influences perceived chest pain. While little is known about this condition, some manifestations include resting tachycardia, exercise intolerance, orthostatic hypotension, and an increased risk of silent myocardial infarction. Critically, providers must maintain a low threshold to assess for cardiac ischemia in diabetic patients and more readily obtain EKGs in triage as well as during the patient's course in the ED to prevent complications from delayed ACS care.
糖尿病（DM）是心血管疾病的主要独立危险因素。出现糖尿病酮症酸中毒（DKA）这种代谢急症的患者有类似的多汗、恶心、呕吐和腹痛症状，这些症状可能掩盖急性冠状动脉综合征（ACS）。我们报告了一例独特病例，腹部和盆腔增强计算机断层扫描（CT）在诊断一名无典型缺血症状患者的急性心肌梗死中发挥了重要作用。一名56岁女性因腹痛、恶心和呕吐就诊于急诊科。她被怀疑患有DKA。开始积极治疗，包括根据体重给予适当剂量的静脉常规胰岛素。由于持续腹痛，进行了腹部和盆腔增强CT检查。检查显示左心室后壁后下部分严重低密度。立即进行了心电图检查，结果与下壁ST段抬高型心肌梗死一致。患者被送往介入心脏病科导管室，在那里发现罪犯病变为左旋支中段100%狭窄。该病例凸显了在诊治出现DKA的糖尿病患者时的许多重要经验教训。糖尿病与心脏自主神经病变（CAN）有关，这种情况会极大地影响对胸痛的感知。虽然对这种情况了解甚少，但一些表现包括静息性心动过速、运动不耐受、体位性低血压以及无症状心肌梗死风险增加。至关重要的是，医疗人员在评估糖尿病患者的心脏缺血时必须保持较低的阈值，在分诊时以及患者在急诊科就诊过程中更应及时进行心电图检查，以防止因急性冠状动脉综合征治疗延迟而出现并发症。
