Anterior myocardial pseudoinfarction in a patient with diabetic ketoacidosis

Background: Patients with Diabetic Ketoacidosis are prone to various life-threatening complications. This case presents a rare presentation of pseudoinfarction in a patient presenting with DKA. Case: 47-year old female with diabetes presented to the hospital with a three-day course of worsening nausea and vomiting. Initial electrocardiogram demonstrated ST elevations on leads V1-V3 concerning for anterior myocardial infarction. She underwent emergent left heart catheterization. During the procedure, the patient was found to have a blood glucose of 985 mg/dL, potassium of 6.7mmol/L, bicarbonate of 8 mmol/L, anion gap of 35 and the diagnosis of diabetic ketoacidosis was made. Cardiac catheterization demonstrated non-obstructive coronary artery disease. Left ventricular end-diastolic pressure obtained concerning for severe dehydration and left vetriculogram noted preserved ejection fraction. She later underwent management for DKA in the medical intensive care unit, including insulin therapy and fluid replacement. One hour afterwards, serum glucose level had improved (613 mg/dL) and the hyperkalemia had resolved (potassium 4.6 mmol/L). Repeat EKG showed normal sinus rhythm with no ST elevations. Decision-Making: Early detection of myocardial infarction is imperative to reduce mortality from this entity. ST segment elevation does not always equal myocardial infarction as demonstrated in this case. An EKG pattern mimicking myocardial infarction with worrisome confounding co-morbid condition such as diabetic ketoacidosis can subject patients to unnecessary invasive management. Conclusion: Hyperkalemia, metabolic acidosis or other metabolic abnormalities and hyperosmolar blood present in DKA can lead to ST segment elevations mimicking a myocardial infarction pattern on EKG. Diabetic Ketoacidosis in 4% of cases may predispose patients to developing acute myocardial infarction and should be considered as a confounding factor in medical or invasive management.