Silent Myocardial Ischemia in Hyperglycemia Patient with LBBB Finding: A Case Study

Author : M.Q. A’yun, Muzaiwirin
Upload Date : 19-04-2018

Introduction: People with diabetes mellitus (DM) have a three to five times higher risk for cardiovascular disease death than nondiabetic subjects. Coronary Artery Disease (CAD), cardiomyopathy, left ventricular hypertrophy (LVH), and conduction abnormality are 4 majors cardiovascular abnormalities in DM patients. Furthermore, cardiac autonomic neuropathy in diabetics patients, has correlation with silent myocardial ischemia (SMI).

Case Illustration: A man, 66 yo, come to emergency department (ED) with nausea and vomiting, onset 8 hours. His skin is cold, wet, and pale. Vital sign in ED BP 81/45mmHg, HR 69 regular, RR 24x/minute, and 36,5 C, with GCS 356. He has history of uncontrolled diabetes mellitus (DM) type 2.

ECG shows LBBB configuration. Laboratory finding was glucose serum 553mg/dL, SGOT 128U/L, SGPT 102U/L. Na 136,1 mmol/L, K 5,01 mmol/L, Cl 97,1 mmol/L, and Troponin I 3.450,5 ng/L. Loading dose Aspirin 320mg and Clopidogrel 300mg had been given.

Discussion: DM is an important risk factor for the cardiovascular complications. Patients with DM had involvement of conduction system like bundle branch block, QT interval abnormalities, and cardiac autonomic neuropathy (CAN).

Left bundle branch block (LBBB) is described as prolongation of QRS duration and therefore asynchrony is visible on ECG. New finding of LBBB in patients with chest pain is a strong predictors of myocardial infarct.

There are concept that patients with diabetes have a higher prevalence of SMI than the general population. Several explanations are possible including a different threshold of pain sensitivity or psychological denial but CAN almost certainly plays an important role.

Conclusion: The presence of CAN is challenging to physician. Physician and hospitals should develop strategies for the rapid recognition and treatment of diabetics patients who present with or without cardiac symptoms.

KEYWORDS : Silent Myocardial Ischemia, Hyperglycemia, Diabetes Mellitus, LBBB

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