An abdominal and pelvic CT scan with IV contrast successfully identified severe hypoattenuation of the left ventricular wall, leading to the diagnosis of an inferior STEMI in a diabetic patient.
Case Report (n=1)
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Abdominal and pelvic CT with IV contrast can incidentally detect myocardial ischemia in diabetic patients presenting with atypical symptoms, highlighting the need for a low threshold for EKG screening in this high-risk population.
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.
Briggs et al. (2022) conducted a case report in ST-Elevation Myocardial Infarction and Diabetic Ketoacidosis (n=1). Abdominal and Pelvic Computed Tomography with IV contrast was evaluated on Diagnosis of acute myocardial infarction. An abdominal and pelvic CT scan with IV contrast successfully identified severe hypoattenuation of the left ventricular wall, leading to the diagnosis of an inferior STEMI in a diabetic patient.