Diabetic Keto Acidosis (DKA), Associated with Failed Thrombolysis with Streptokinase in Acute Myocardial Infarction

Sai Soundarya*

DNB Internal Medicine Resident, Kauvery Heart City, Trichy, India

*Correspondence: saisoundharyakumarasamy@gmail.com

Abstract

Streptokinase has been used as a thrombolytic agent in the treatment of AMI ever since 1958 when Sherry and others started using streptokinase in acute MI. This changed the focus of treatment of MI from symptomatic to specific. There are several factors that can cause failure of thrombolysis in MI. There are very few studies on DKA as a contributing factor for failure of thrombolysis in MI with Streptokinase. This article documents failed thrombolysis with Streptokinase in the setting of diabetic ketoacidosis in a patient with who presented with large anterior wall transmural infarct.

Keywords: Diabetic ketoacidosis, Streptokinase, Acute myocardial infarction, Criteria for successful lysis

Background

The association of diabetic ketoacidosis and myocardial infarction is very frequent. These two conditions can trigger each other and, in many instances, we would not know which played the causative role. There are so many reasons for failure of thrombolysis in myocardial infarction in diabetic patients [1]. We report a patient who presented with anterior wall MI and DKA, and failed iv thrombolysis with Streptokinase.

Case Presentation

A 64-years-old gentleman, with sedentary lifestyle, recently diagnosed to have type 2 diabetes two months earlier, on oral hypoglycemics, with no high-risk practices of smoking or alcohol, and no family history of diabetes or CAD, was admitted with complaints of chest pain and back pain for 4 h.

On Examination

HR: 84/min, BP: 140/80 mmHg, SpO2: 88% in RA, JVP: not elevated, RR: 36/min

CVS: S1, S2, S3 +, Lungs: Bilateral basal crepitations +, No ascites or pedal edema, all peripheral pulses felt

Investigations

CBG: 286 mg/dL

Total count: 12, 700 with 72% neutrophils

Serum amylase:19, Serum lipase :65

Urine routine:1-2 pus cells

Electrolytes: sodium 133; potassium: 3.92

Troponin T: positive

 

Arrival ECG

Arrival-ECG

 

ECG showed significant ST segment elevation in anterior and lateral leads, with reciprocal depression in the inferior leads.

ECHO: regional wall motion abnormality (mid antero- septum, anterior wall, apical septum, anterior wall LV apex and lateral wall were akinetic), with severe LV systolic dysfunction, with grade 2 diastolic dysfunction and mild MR, mild PAH.

Since the patient’s attenders were not willing for percutaneous coronary intervention, he underwent thrombolysis with Streptokinase which was given 4 h 10 min from the onset of chest pain (pain to needle time). He was given streptokinase since he couldn’t afford for recombinant tissue plasminogen activator.

ECG taken 1.5 h and 6 h post lysis showed persistent ST segment elevation in anterior and lateral leads which indicated failure of lysis.

 

ECG

ECG post 1.5 h of lysis:

 

ECG taken 1.5 h post lysis showed a failure of reduction of ST segment elevation by at least 75% in anterior leads V2-V4. and resolution of ST segment elevation in lateral leads 1, aVL and V5,V6.

ECG post 6 of lysis:

 

ECG-post-6-of-lysis

 

ECG taken 6 h post lysis also showed persistence of ST segment elevation in leads V2 and V3 indicating failure of lysis.

Patient had persistent vomiting since admission. Acute pancreatitis and Diabetic ketoacidosis were considered. Serum amylase, lipase, ABG, plasma and urine acetone were sent. Serum amylase and lipase were normal. ABG showed metabolic acidosis with elevated blood sugar level (400 mg/dL) and urine acetone was positive. He was diagnosed to have Diabetic ketoacidosis. CBC and urine routine were normal, suggesting no infective cause of DKA. He was started on insulin infusion.

Discussion

Criteria for successful lysis

Signs of successful reperfusion after thrombolytic therapy are:

  1. relief of chest pain
  2. resolution of initial ST segment elevation by 50 and 75% at the end of 60 and 90 min post lysis, respectively.
  3. Early appearance of q or Q waves
  4. Sudden rise in cardiac enzymes as reperfusion occurs
  5. Occurrence of reperfusion arrhythmias

Common causes for failure of thrombolysis in MI:

  1. Delayed presentation
  2. Old age
  3. Smoking
  4. Alcoholism
  5. Diabetes
  6. Systemic hypertension

In a study, conducted by Zaires et al in Greece [2], Diabetes was considered a strong predictor of failure of thrombolysis in Acute Myocardial infarction, which was also seen in our patient. Diabetes in MI patients can also precipitate cardiogenic shock, congestive heart failure and conduction abnormalities apart from failure of thrombolysis. Mortality in AMI is higher in the presence of DKA.

Conclusion

In this case we found an association of diabetic ketoacidosis in patient who had failure of iv thrombolysis for myocardial infarction. We propose to follow up and study the number of patients with DKA who achieve successful thrombolysis and those with DKA who had failure of thrombolysis and find out whether they are significantly associated.

References

  1. Sherry S, et al. The enzymatic dissolution of experimental arterial thrombi in the dog by trypsin, chymotrypsin and plasminogen activators. J Clin Invest. 1954;33:1303-13.
  2. Zaires, et al. Diabetes Care 2004;27(4):967-71.
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Dr. Sai Soundarya

DNB Internal Medicine Resident

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