A 60 year old woman suffering from hypertension secondary to diabetic nephropathy was being followed up in a nephrology clinic. Her leg was amputated four years ago. At her fifth day of admission she had been seen by a cardiologist because of chest discomfort lasting 20 minutes and ST elevations on her electrocardiogram (ECG) (fig 1). Blood pressure was 150/80 mm Hg and heart rate 75 beats/min. A pansystolic murmur graded 3/6 was heard at the apex. Neither gallop sounds nor pulmonary rales were present. She was taken to the coronary care unit; aspirin, heparin, and nitrate were started.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Serial ECGs of the patient.

Laboratory analyses, performed at follow up in the nephrology clinic, were as follows: haemoglobin 94 g/l, packed cell volume 0.29, urea 43.2 mmol/l, creatinine 406.6 μmol/l, sodium 126 mmol/l, potassium 3.5 mmol/l, creatine kinase MB fraction 12 U/l. The latter was in normal limits during the first 24 hours. The ECG before her complaint showed coarse atrial fibrillation without ST change. The ECG findings persisted 72 hours despite recovery of the symptom in 20 minutes and the one recorded at fourth day was completely identical with the baseline. Tc-99m pyrophosphate myocardial scintigraphy performed 48 hours after the event showed no necrosis.