Pregabalin and atypical NSTEMI presentation in a diabetic woman (masked myocardial ischemia): A case report

TL;DR

A diabetic woman with atypical symptoms was found to have a heart attack, highlighting the challenges in diagnosing heart issues in diabetic patients.

Contribution

Highlights the diagnostic challenge of atypical ACS in diabetic women and the role of pregabalin in delayed recognition of ischemia.

Findings

The patient presented with nausea and vomiting instead of chest pain, a common sign of heart attack.

Serial ECGs and biomarker trending were critical in diagnosing severe multivessel coronary artery disease.

Pregabalin use may contribute to delayed recognition of myocardial ischemia in diabetic patients.

Abstract

Women with non-ST-elevation myocardial infarction frequently present with atypical symptoms, particularly those with diabetes, in whom autonomic neuropathy can blunt the perception of ischemic pain. The present study reports the case of a 57-year-old female patient with type 2 diabetes, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, obesity and chronic pregabalin use who presented with nausea and bilious vomiting without chest pain. An initial evaluation revealed mildly elevated high sensitivity troponin T, non-specific electrocardiogram (ECG) changes and normal abdominal imaging. Acute coronary syndrome (ACS) was initially considered unlikely, and the patient was discharged following an improvement in her symptoms. However, within 24 h, she re-presented with recurrent gastrointestinal symptoms and new periumbilical pain. Repeat ECG demonstrated diffuse ST-segment depressions and T wave inversions with upright T waves in aVR and V1. A subsequent echocardiography revealed a reduced ejection fraction (25-30%), and coronary angiography confirmed severe multivessel coronary artery disease. The present case report underscores the diagnostic challenge of atypical ACS in diabetic women, highlights the critical value of serial ECGs and biomarker trending in high-risk patients, and raises awareness of gabapentinoid therapy, such as pregabalin, as a potential contributor to the delayed recognition of myocardial ischemia. Early, repeated ECG evaluations should be prioritized even in the absence of chest pain to prevent the missed or delayed diagnosis of life-threatening coronary disease.

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