Skill Checkup: Man With a History of Type 2 Diabetes Complicated by Peripheral Neuropathy Presents With New Dyspnea

Alanna Morris, MD


January 27, 2022

Based on this patient's test results, myocardial infarction is diagnosed. Atherosclerotic cardiovascular disease is the leading cause of death among individuals with type 2 diabetes. Atherosclerotic cardiovascular disease is strongly associated with chronic hyperglycemia, insulin resistance, and/or diabetes and is characterized by focal deposits of lipids, complex carbohydrates, blood products, fibrous elements, and calcium deposits in the arterial intima; medial changes may also develop. In its early stages, atherosclerosis remains clinically silent; when it progresses, atherosclerotic cardiovascular disease can ensue. Key manifestations of atherosclerotic cardiovascular disease in diabetes include coronary heart disease, ischemic stroke, peripheral artery disease, and heart failure. Patients with atherosclerotic cardiovascular disease and concomitant diabetes are at exceptionally high risk for new and recurrent ischemic events and heart failure.

In addition to ECG, the patient's history is a critical factor in the diagnosis of myocardial infarction. In some cases, it may provide the only clues that lead to diagnosis in the early stages of presentation. Many patients present with intense retrosternal chest pain that frequently radiates up to the neck, shoulder, and jaws, and down to the left arm and is unremitting for 30-60 minutes. However, some patients may not recognize the chest pain, have an exceptionally high pain threshold, or have a disorder (such as diabetes) that impairs pain perception and results in a defective anginal warning system. Others may have altered mental status from medications or impaired cerebral perfusion. Elderly patients with preexisting altered mental status or dementia may have no memory of recent symptoms and may have no complaints of any kind.

Additional symptoms of myocardial infarction may include:

  • Anxiety, commonly described as a sense of impending doom

  • Pain or discomfort in the arms, left shoulder, back, neck, jaw, or stomach

  • Weakness or lightheadedness, with or without syncope

  • Cough

  • Nausea or indigestion, with or without vomiting

  • Profuse sweating

  • Shortness of breath

  • Wheezing

  • Rapid or irregular heart rate

  • Fullness or choking feeling


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