EXTREME ECG AND TROPONIN ABNORMALITIES IN DIABETIC KETOACIDOSIS IN THE ABSENCE OF AN ACUTE CORONARY SYNDROME

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Although troponin I (TnI) elevation indicates myocardial injury, the majority of instances are not due to an acute coronary syndrome (ACS). CASE PRESENTATION: A 57 year old female presented with diabetic ketoacidosis (DKA) 5 months after CABG. She was hemodynamically stable with mild tachycardia and a normal cardiopulmonary examination. Serum glucose was > 1250, pH= 7.16, K+ =8.3. CXR and sepsis evaluation was negative. The ECG revealed ST elevation in V1-2 and aVR with diffuse ST segment depression and peaked T-waves (Figure 1A). Initial TnI (4th generation) was 0.079 and peaked at 63.2 ng/mL (Figure 1B). The patient had no cardiopulmonary complaints and an echocardiogram revealed hyperdynamic function with an LVEF of 70% without wall motion abnormalities. Treatment with IV fluid and insulin normalized K+ and pH, as the ECG returned to baseline. Myocardial infarction commonly causes death in the first 24 hours of DKA. This patient had known CAD, a markedly abnormal ECG and marked troponin elevation, but no clinical or imaging evidence of ACS. Cardiac catheterization was not pursued. DISCUSSION: Various metabolic derangements accompany DKA including hypo and hyperkalemia, hyponatremia and metabolic acidosis. Hyperkalemia is well known to present with ECG pseudoinfarct pattern including ST elevations and peaked T waves in the setting of severe academia. Likewise, hypokalemia can depress ST segments and cause T wave inversion. Free fatty acid elevation itself can disrupt cell membranes and release troponin. Our patient lacked other findings typically seen in demand ischemia. Such isolated troponin elevation has been seen in up to 27% of patients with DKA in the absence of ACS1. CONCLUSIONS: With the dawn of more sensitive troponin assays, caution will need to be taken interpreting troponin in non-ACS settings, as specificity for ACS may be reduced. Reference #1: Al-Mallah, M., Zuberi, O., Arida, M., & Kim, H. E. (2008). Positive Troponin in Diabetic Ketoacidosis without Evident Acute Coronary Syndrome Predicts Adverse Cardiac Events. Clinical Cardiology,31(2), 67-71. https://doi.org/10.1002/clc.20167 DISCLOSURES: No relevant relationships by Gilead Lancaster, source=Web Response No relevant relationships by Craig McPherson, source=Web Response No relevant relationships by Tony Roy, source=Web Response No relevant relationships by Kristin Stawiarski, source=Web Response No relevant relationships by stuart zarich, source=Web Response