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Letter to the Editor
Stress cardiomyopathy and euglycemic ketoacidosis in a patient treated with sodium-glucose cotransporter type 2
Miocardiopatía de estrés y cetoacidosis euglucémica en una paciente tratada con inhibidores del cotransportador sodio-glucosa tipo 2
Martín Negreira Caamañoa,
Corresponding author
martin.negcam@gmail.com

Corresponding author.
, Ariana Gonzálvez Garcíab, Luis Javier Yuste Domínguezc
a Servicio de Cardiología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
b Unidad de Hemodinámica, Servicio de Cardiología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
c Servicio de Medicina Intensiva, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sodium-glucose cotransporter type 2 inhibitors &#40;SGLT2i&#41; are an attractive therapeutic option in diabetic patients due to a combination of cardiovascular and renal clinical benefits and an excellent safety profile&#46; However&#44; an increased risk of developing diabetic ketoacidosis has been reported in patients treated with these drugs&#44; especially in those receiving concomitant insulin treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the other hand&#44; stress cardiomyopathy &#40;SC&#41; is a reversible acute heart disease that is triggered by physical or emotional stress&#46; We describe a case of SC occurring in the context of euglycemic diabetic ketoacidosis &#40;EDKA&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 64-year-old woman presented to the emergency department with a 2-day history of nausea&#44; vomiting and abdominal pain&#46; Furthermore&#44; in the last 24&#8239;h she reported a sharp increase in the rate of diuresis&#46; She denied chest pain&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">She had a history of type 2 diabetes with poor glycaemic control and was being treated with three oral antidiabetic drugs &#40;metformin&#44; dapagliflozin&#44; sitagliptin&#41; and insulin glargine&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On examination&#44; she had tachypnoea and pain on abdominal palpation&#46; Cardiopulmonary auscultation was unremarkable&#46; An electrocardiogram revealed decreased voltages with pathological Q waves and a discrete ST-segment elevation in V1&#8211;V3&#44; as well as generalised negative T waves&#46; A blood test revealed an elevated ultrasensitive troponin-<span class="elsevierStyleSmallCaps">I</span> &#40;4836&#8239;ng&#47;dl&#59; reference value&#8239;&#60;&#8239;20&#8239;ng&#47;dl&#41;&#44; while the creatine kinase value was normal &#40;162&#8239;mg&#47;dl&#41;&#46; Metabolic acidosis was also identified &#40;pH 7&#46;18&#59; bicarbonate 14&#8239;mmol&#47;l&#59; PCO<span class="elsevierStyleInf">2</span>&#58; 30&#46;1&#8239;mmHg&#59; lactate 26&#8239;mmol&#47;l&#41;&#46; Blood glucose was slightly elevated &#40;166&#8239;mg&#47;dl&#41;&#46; Urinalysis revealed the presence of severe ketonuria and glycosuria &#40;&#43;&#43;&#43;&#43;&#41;&#46; An abdominal CT scan showed unremarkable findings&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">An echocardiogram was then requested&#44; where a severely reduced left ventricular ejection fraction was identified at the expense of a mid-apical akinesia&#44; with no associated valvular heart disease or other complications&#46; An urgent coronary angiography was performed&#44; in which the presence of obstructive coronary lesions was ruled out&#44; while the ventriculography again showed apical ballooning&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Acidosis resolution was achieved with the infusion of saline and bicarbonate&#44; and ketonuria became negative within 24&#8239;h&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cardiac study was completed with an MRI &#40;1&#46;5 Tesla&#41; performed on the eighth day after admission&#44; where the absence of late gadolinium uptake at myocardial level was confirmed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">After 9 days of hospitalisation the patient was discharged&#46; She was re-evaluated in an outpatient clinic one month later&#44; with a normal electrocardiogram and echocardiogram&#44; confirming the diagnosis of SC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Different mechanisms have been suggested to be involved in the pathophysiology of SC&#58; dysregulation of the central nervous system&#44; increased plasma catecholamines&#44; hyperproduction of stress hormones&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although emotional triggers were first described as being associated with SC&#44; current registries place physical triggers as the most common&#46; Diabetic ketoacidosis has previously been described as a trigger for SC&#46; The case described&#44; however&#44; developed in the context of EDKA&#44; a rare form of diabetic ketoacidosis&#46; Although formal definitions are lacking&#44; EDKA is usually characterised by the concomitant presence of metabolic acidosis&#44; ketonemia&#47;ketonuria and normal - or slightly elevated - blood glucose&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">SGLT-2i are considered the main factor associated with the development of EDKA in our setting&#46; The glycosuria generated by these drugs leads to a decrease in blood glucose levels that stimulates the production of glucagon&#44; which acts to promote lipolysis and the production of ketones in the liver&#46; These mechanisms are in turn enhanced by an increase in preproglucagon production due to the direct action of SLGLT-2i on gene expression in pancreatic cells&#945;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The occurrence of EDKA is rare in patients treated with SGLT-2i monotherapy&#44; with most cases reported with concomitant insulin therapy&#46; Ketogenic states such as prolonged fasting&#44; intense exercise or a critical clinical situation are often described as associated risk factors&#46; It is therefore sensible to avoid treatment with SGLT-2i in these scenarios&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This research has not received any funding&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest related to this research work&#46;</p></span></span>"
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Article information
ISSN: 23870206
Original language: English
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