The heart is a major target organ for insulin, and marked changes in cardiac function occur in patients with diabetes mellitus. 16 Whether type 1 or type 2, coronary artery disease accounts for more than half of deaths in diabetics.16 Factors contributing to the diabetic cardiac dysfunction are increased incidence of atherosclerosis of the coronary arteries, autonomic neuropathy, and microvascular disease (associated with hypertension and renal disease). Diabetics are prone to "silent" myocardial infarction, or infarction associated with atypical symptoms, such as weakness. Even in the absence of vascular disease and hypertension, some diabetics develop cardiomegaly, with systolic and diastolic ventricular dysfunction that may evolve into congestive heart failure. 17 Diabetic cardiomyopathy may be a direct effect of insulin deficiency or resistance on myocardial cell function. The detrimental effects of diabetes mellitus on the heart are more prominent in young diabetics and women.17 Women usually have a lower risk of coronary artery disease but diabetes renders them more vulnerable to reinfarction and death after myocardial infarction and congestive heart failure. Vascular disease in diabetics may be either nonspecific (atherosclerosis of large vessels) or specific (microangiopathic disease in small vessels) for diabetes.
Most standard emergency department treatments for hypertension and cardiac disease can be utilized in diabetics with appropriate precautions. Moderate to severely elevated glucose levels should be decreased by utilizing small intravenous doses of regular insulin, but the glucose level should not be tightly controlled; the patient is undergoing a stressful event and the added stress and consequences of hypoglycemia should be avoided. There is a risk for intraocular bleed from thrombolytic administration to a diabetic with proliferative retinopathy. Even though the risk of intraocular bleed is low, proliferative retinopathy is an absolute contraindication to thrombolytic therapy. The challenge to the emergency physician is expedient evaluation for proliferative retinopathy while simultaneously evaluating the need for thrombolytics.
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