Scientific letter
Transient electrocardiographic abnormalities during hypoglycemia
Alteraciones electrocardiográficas transitorias durante un episodio de hipoglucemia
Manuel José Fernández Anguita
, Virgilio Martínez Mateo, Laura Cejudo del Campo Díaz, Miguel Ángel Villanueva Terrazas, Antonio Jesús Paule Sánchez
Corresponding author
Servicio de Cardiología, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
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1000 "Tamanyo" => 72050 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Normalization of changes in the ST segment and repolarization after correction of hypoglycemia with intravenous hypertonic glucose.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypoglycemia, defined as plasma glucose levels <70<span class="elsevierStyleHsp" style=""></span>mg/dL, is a potentially serious complication occurring in 40% of patients with type 1 diabetes mellitus, and less commonly in patients with type 2 diabetes mellitus.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Different changes in the electrocardiogram (ECG) associated with hypoglycemia have been reported.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The case of a female patient referred to the emergency room of our hospital for loss of consciousness is reported below. This was a 74-year-old woman with long-standing diabetes on treatment with metformin 850<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and Lantus<span class="elsevierStyleSup">®</span> insulin 30<span class="elsevierStyleHsp" style=""></span>IU at dinner. She was also being treated with pravastatin 10<span class="elsevierStyleHsp" style=""></span>mg and Eutirox<span class="elsevierStyleSup">®</span> 50<span class="elsevierStyleHsp" style=""></span>μg for dyslipidemia and hypothyroidism respectively. At admission, the patient was unconscious, with no response to verbal or painful stimuli and mydriatic, nonreactive pupils. She was breathing spontaneously. Her blood pressure was 110/75<span class="elsevierStyleHsp" style=""></span>mmHg, and heart rate 56<span class="elsevierStyleHsp" style=""></span>bpm. Heart auscultation revealed cardiac rhythmic sounds, with no murmurs, and pulmonary auscultation found no pathological sounds. The initial capillary blood glucose level was 35<span class="elsevierStyleHsp" style=""></span>mg/dL. Intravenous infusion of hypertonic glucose resulted in the recovery of consciousness and increased the blood glucose level to 280<span class="elsevierStyleHsp" style=""></span>mg/dL. Laboratory test results included: chemistry: urea, 49<span class="elsevierStyleHsp" style=""></span>mg/dL; creatinine, 1.2<span class="elsevierStyleHsp" style=""></span>mg/dL; sodium, 141<span class="elsevierStyleHsp" style=""></span>mEq/L; potassium, 3.9<span class="elsevierStyleHsp" style=""></span>mEq/L; chloride, 112<span class="elsevierStyleHsp" style=""></span>mEq/L; troponin Ic (peak value), 2.1<span class="elsevierStyleHsp" style=""></span>μg/dL; baseline arterial blood gases: pH 7.42, <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span> 35<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span> 75<span class="elsevierStyleHsp" style=""></span>mmHg, HCO<span class="elsevierStyleInf">3</span> 22<span class="elsevierStyleHsp" style=""></span>mmol/L; complete blood count: WBCs, 8760/μL; hemoglobin, 11.8<span class="elsevierStyleHsp" style=""></span>g/dL; and platelets, 316,000/μL. The ECG at admission (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed sinus rhythm at 62<span class="elsevierStyleHsp" style=""></span>bpm with signs of left ventricular hypertrophy, 1<span class="elsevierStyleHsp" style=""></span>mm ST segment elevation in aVR, and 1<span class="elsevierStyleHsp" style=""></span>mm ST segment depression in <span class="elsevierStyleSmallCaps">II</span>, <span class="elsevierStyleSmallCaps">III</span>, aVF, and V4–6 with generalized asymmetrical negative T waves, and a QTc interval of 510<span class="elsevierStyleHsp" style=""></span>ms. The ECG performed after the correction of hypoglycemia with intravenous hypertonic glucose (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) showed a normalization of changes in the ST segment and repolarization, and the persistence of left ventricular hypertrophy (a pattern of diastolic overload with asymmetrical negative T wave in <span class="elsevierStyleSmallCaps">I</span>, aVL, and V5–6). While the patient reported no chest pain, the slightly elevated troponin Ic level prompted the performing of an echocardiogram which showed moderate concentric hypertrophy and normal LVEF, and a treadmill exercise test which was electrically and clinically negative. The course of the patient in the ward was favorable, with good blood glucose control. She was discharged on Lantus<span class="elsevierStyleSup">®</span> insulin 46<span class="elsevierStyleHsp" style=""></span>IU at lunch time, and a rescue regimen of rapid-acting insulin based on the blood glucose level (less than 80<span class="elsevierStyleHsp" style=""></span>mg/dL: none; 81–130<span class="elsevierStyleHsp" style=""></span>mg/dL: 4<span class="elsevierStyleHsp" style=""></span>IU; 131–200<span class="elsevierStyleHsp" style=""></span>mg/dL: 7<span class="elsevierStyleHsp" style=""></span>IU; 201–250<span class="elsevierStyleHsp" style=""></span>mg/dL: 8<span class="elsevierStyleHsp" style=""></span>IU; 251–300<span class="elsevierStyleHsp" style=""></span>mg/dL: 10<span class="elsevierStyleHsp" style=""></span>IUI; over 300<span class="elsevierStyleHsp" style=""></span>mg/dL: 14<span class="elsevierStyleHsp" style=""></span>IU), with the discontinuation of metformin.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Various electrocardiographic changes associated with hypoglycemia have been reported. Their incidence is unknown, as most data found in the literature come from isolated case reports. ST segment and repolarization changes, T-wave flattening and inversion, QT interval prolongation, as well as sinus tachycardia and bradycardia, various degrees of atrioventricular block, atrial fibrillation or supraventricular or ventricular extrasystole,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> and even the induction of fatal arrhythmia have been seen.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The mechanisms of the electrocardiographic changes associated with hypoglycemia have not been fully elucidated. However, the direct effect of hypoglycemia, increased epinephrine secretion, secondary hypokalemia, and autonomic dysfunction have been suggested.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Glucose is vital for myocardial metabolism, and hypoglycemia may be associated with deficient energy provision to the cell. On the other hand, secondary sympathoadrenal discharge increases oxygen consumption, and may also decrease the oxygen supply by vasoconstriction. All these factors may cause a significant impairment in cell metabolism The decrease in serum potassium levels that may occur with hypoglycemia could explain the changes in the ST segment, T wave, and QT interval,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> favored by excess circulating epinephrine levels.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In an experimental study reported in 1975, Libby et al. stated that in hypoglycemia, ST depression occurred in territories without coronary artery disease, while elevation occurred in those supplied by obstructed coronary arteries.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Maroto et al., however, reported the case of a young patient with ST segment elevation concurrent with hypoglycemia and with normal coronary arteries, and suggested that these changes resulted from a maximum degree of diastolic depolarization of cardiac myofibril caused by changes in intracellular potassium concentrations.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It may be concluded that in any patient with diabetes who experiences ECG, hypoglycemia should be suspected as a cause.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Anguita MJ, Martínez Mateo V, Cejudo del Campo Díaz L, Villanueva Terrazas MÁ, Paule Sánchez AJ. Alteraciones electrocardiográficas transitorias durante un episodio de hipoglucemia. Endocrinol Nutr. 2016;63:96–97.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 640 "Ancho" => 1000 "Tamanyo" => 55170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sinus rhythm at 62<span class="elsevierStyleHsp" style=""></span>bpm. 1<span class="elsevierStyleHsp" style=""></span>mm ST segment depression in II, III, aVF, and V4–6 (arrows) with generalized, asymmetrical negative T waves and a QTc interval of 510<span class="elsevierStyleHsp" style=""></span>ms.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 72050 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Normalization of changes in the ST segment and repolarization after correction of hypoglycemia with intravenous hypertonic glucose.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanisms of hypoglycemia unawareness and implications in diabetic patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. 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Yasin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Presse Med" "fecha" => "1994" "volumen" => "23" "paginaInicial" => "78" "paginaFinal" => "79" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8140076" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Modification by propranolol of cardiovascular effects of induced hypoglycaemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.H. Lloyd-Mostyn" 1 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 28 | 0 | 28 |
| 2024 October | 139 | 23 | 162 |
| 2024 September | 141 | 13 | 154 |
| 2024 August | 158 | 16 | 174 |
| 2024 July | 121 | 8 | 129 |
| 2024 June | 116 | 9 | 125 |
| 2024 May | 98 | 2 | 100 |
| 2024 April | 132 | 10 | 142 |
| 2024 March | 127 | 10 | 137 |
| 2024 February | 145 | 16 | 161 |
| 2024 January | 182 | 14 | 196 |
| 2023 December | 139 | 19 | 158 |
| 2023 November | 165 | 8 | 173 |
| 2023 October | 219 | 10 | 229 |
| 2023 September | 150 | 11 | 161 |
| 2023 August | 147 | 7 | 154 |
| 2023 July | 157 | 13 | 170 |
| 2023 June | 95 | 4 | 99 |
| 2023 May | 156 | 6 | 162 |
| 2023 April | 97 | 6 | 103 |
| 2023 March | 120 | 8 | 128 |
| 2023 February | 122 | 5 | 127 |
| 2023 January | 85 | 5 | 90 |
| 2022 December | 104 | 13 | 117 |
| 2022 November | 120 | 8 | 128 |
| 2022 October | 118 | 14 | 132 |
| 2022 September | 125 | 17 | 142 |
| 2022 August | 100 | 13 | 113 |
| 2022 July | 83 | 14 | 97 |
| 2022 June | 106 | 11 | 117 |
| 2022 May | 95 | 12 | 107 |
| 2022 April | 209 | 26 | 235 |
| 2022 March | 134 | 14 | 148 |
| 2022 February | 78 | 13 | 91 |
| 2022 January | 101 | 10 | 111 |
| 2021 December | 89 | 12 | 101 |
| 2021 November | 91 | 13 | 104 |
| 2021 October | 113 | 18 | 131 |
| 2021 September | 111 | 10 | 121 |
| 2021 August | 120 | 8 | 128 |
| 2021 July | 102 | 7 | 109 |
| 2021 June | 94 | 12 | 106 |
| 2021 May | 122 | 17 | 139 |
| 2021 April | 220 | 21 | 241 |
| 2021 March | 191 | 24 | 215 |
| 2021 February | 99 | 14 | 113 |
| 2021 January | 111 | 18 | 129 |
| 2020 December | 119 | 17 | 136 |
| 2020 November | 120 | 20 | 140 |
| 2020 October | 86 | 12 | 98 |
| 2020 September | 94 | 15 | 109 |
| 2020 August | 118 | 20 | 138 |
| 2020 July | 125 | 23 | 148 |
| 2020 June | 144 | 18 | 162 |
| 2020 May | 231 | 35 | 266 |
| 2020 April | 61 | 37 | 98 |
| 2020 March | 83 | 7 | 90 |
| 2020 February | 73 | 6 | 79 |
| 2020 January | 91 | 6 | 97 |
| 2019 December | 73 | 12 | 85 |
| 2019 November | 76 | 8 | 84 |
| 2019 October | 88 | 6 | 94 |
| 2019 September | 93 | 1 | 94 |
| 2019 August | 71 | 13 | 84 |
| 2019 July | 108 | 11 | 119 |
| 2019 June | 176 | 21 | 197 |
| 2019 May | 341 | 56 | 397 |
| 2019 April | 189 | 39 | 228 |
| 2019 March | 75 | 8 | 83 |
| 2019 February | 41 | 13 | 54 |
| 2019 January | 25 | 7 | 32 |
| 2018 December | 12 | 7 | 19 |
| 2018 November | 20 | 11 | 31 |
| 2018 October | 24 | 5 | 29 |
| 2018 September | 34 | 9 | 43 |
| 2018 August | 6 | 3 | 9 |
| 2018 July | 3 | 2 | 5 |
| 2018 June | 7 | 6 | 13 |
| 2018 May | 8 | 2 | 10 |
| 2018 April | 8 | 2 | 10 |
| 2018 March | 4 | 1 | 5 |
| 2018 February | 6 | 1 | 7 |
| 2018 January | 12 | 1 | 13 |
| 2017 December | 8 | 1 | 9 |
| 2017 November | 17 | 0 | 17 |
| 2017 October | 15 | 3 | 18 |
| 2017 September | 15 | 3 | 18 |
| 2017 August | 19 | 5 | 24 |
| 2017 July | 12 | 1 | 13 |
| 2017 June | 25 | 7 | 32 |
| 2017 May | 28 | 16 | 44 |
| 2017 April | 17 | 10 | 27 |
| 2017 March | 36 | 32 | 68 |
| 2017 February | 57 | 6 | 63 |
| 2017 January | 4 | 1 | 5 |
| 2016 December | 16 | 5 | 21 |
| 2016 November | 19 | 2 | 21 |
| 2016 October | 26 | 2 | 28 |
| 2016 September | 32 | 3 | 35 |
| 2016 August | 19 | 4 | 23 |
| 2016 May | 0 | 1 | 1 |
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