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Painless acute myocardial infarction and diabetes mellitus

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With diabetes mellitus, painless acute myocardial infarctus (PAMI) is a well-known clinical phenomen. Possible explanations include microangiopathy, diabetic neuropathy and abnormalities in myocardial metabolism in humans (hyperinsulinemia, hyperglycemia and insulin resistance).

Various studies show that with diabetes mellitus approximately 25–50% of AMI presents with only slight pain or without pain. For emergency prehospital services this feature plays an extremely important differential diagnostic role.

This is a presentation of our clinical experiences from January 1995 to September 1997. During this period, we dealt with 69 (28 female and 41 male) cases of AMI with patients suffering from diabetes.

All the patients had previously been registered at the regional diabetes center and had undergone treatment: 22 (31.8%) with insulin therapy and 47 (68.2%) with oral antidiabetes medicine. The average age of the patients was 51.3 ± 5.8 years.

All the patients underwent the ECG and enzyme analysis of AMI and preinterventional blood glucose levels. Thirty-two patients had no cardiac pain, only non-specific symptomatology (nausea, vomiting, dyspnea, perspiration, tiredness, palpitations, non-specific precordial sensations) or a dominating clinical picture of hyperglycemia (ketoacidosis) or hypoglycemia. For 4 patients we were not able to obtain relevant anamnestic/heteroanamnestic data.

Hyperglycemia (15.3–31.5 mmol/l; 20.61 ± 4.08) was verified in 43 patients (62.3%), of them 5 cases with coma (ketoacidosis).

Hypoglycemia (0.8–2.0 mmol/l; 1.47 ± 0.43) was registered in 11 patients (15.1%), of them 2 cases with coma.

Euglycemia (3.52–6.37 mmol/l; 5.28 ± 0.82) was registered in 15 patients (22.6%).


PAMI must to be excluded in the treatment of an emergency patient for whom there is an anamnestic or heteroanamnestic record of diabetes. Treatment of ketoacidosis should be carried out promptly, because of the high mortality rate with already developed ketoacidosis-coma and AMI. It is vital that the differential diagnosis is carried out promptly and accurately to ensure accurate and prompt therapeutic treatment.

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Grmec, Š. Painless acute myocardial infarction and diabetes mellitus. Crit Care 2 (Suppl 1), P052 (1998).

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