Concurrent Diabetic Ketoacidosis and Non-ST-Elevation Myocardial Infarction: A Complex Cardiometabolic Emergency

Diabetic ketoacidosis (DKA) is a severe diabetic emergency usually triggered by an infection or missed insulin doses. Concurrent myocardial infarction, though an uncommon precipitating factor, complicates diagnosis and management due to overlapping clinical features and contradictory management challenges. We report the case of a 51-year-old male patient with type 2 diabetes mellitus, hypertension, and dyslipidemia, who presented with a two-day history of central chest pain radiating to the left arm, associated with nausea, vomiting, exertional dyspnea, and orthopnea. On examination, he was hypotensive, tachycardic, and clinically dehydrated. Initial investigations revealed sinus tachycardia with ST-segment depression in leads V4, V5 and V6 on ECG, severe hyperglycemia (glucose 20.1 mmol/L), ketonemia (>7 mmol/L), and high anion gap metabolic acidosis (pH 7.06, bicarbonate 9 mmol/L), confirming DKA. Management was initiated with intravenous fluid resuscitation and insulin infusion. Troponin T was elevated at 56.2 ng/L, raising concern for non-ST-elevation myocardial infarction (NSTEMI). The cardiology team recommended conservative management with dual antiplatelet therapy, statins, beta-blockers, ACE inhibitors, and low molecular weight heparin. The patient required non-invasive ventilation in the ICU due to oxygen desaturation and pulmonary congestion. Serial troponins peaked at 429 ng/L. Coronary angiography revealed multi-vessel coronary artery disease. Transthoracic echocardiography showed regional wall motion abnormalities with an ejection fraction (EF) of 40-45%. The patient subsequently underwent coronary artery bypass grafting (CABG) at an external center and has since shown favorable recovery. This case underscores the rare but clinically significant presentation of NSTEMI-induced DKA. The systemic inflammatory state and catecholamine surge during myocardial infarction may precipitate metabolic decompensation in patients with diabetes. Co-management requires a careful balance between aggressive fluid resuscitation for DKA and the risk of exacerbating cardiac dysfunction. Early recognition, multidisciplinary coordination, and risk stratification are essential for optimizing outcomes.