Abstract Body (Do not enter title and authors here): Background: Diabetic ketoacidosis (DKA) generates profound metabolic derangements that can lead to myocardial oxygen supply-demand imbalance, predisposing patients to Type 2 myocardial infarction (MI). However, the prognostic significance of Type 2 MI in the setting of DKA remains poorly defined.

Methods: We analyzed adult hospitalizations with a primary diagnosis of DKA using the Nationwide Readmissions Database (2018–2022). Patients were stratified by the presence of a secondary diagnosis of Type 2 MI. To minimize confounding, 1:1 propensity score matching was performed, balancing for demographics, comorbidities, and hospital characteristics. Outcomes included in-hospital mortality, discharge to a skilled nursing facility (SNF), total hospitalization cost, length of stay (LOS), and 30-day all-cause readmissions. Associations were assessed using multivariable logistic and negative binomial regression models.

Results: Among 448,542 DKA hospitalizations, 5,824 (1.3%) were complicated by Type 2 MI. After matching, patients with Type 2 MI exhibited significantly higher in-hospital mortality compared with those without Type 2 MI (3.5% vs. 1.9%; adjusted odds ratio [aOR], 1.85; 95% confidence interval [CI], 1.46–2.35; p<0.001). Type 2 MI was also associated with increased discharge to SNF (18.9% vs. 16.8%; aOR, 1.24; 95% CI, 1.12–1.37; p<0.001), 58% greater hospitalization costs (adjusted coefficient, 0.42; 95% CI, 0.35–0.49; p<0.001), and 72% longer LOS (adjusted coefficient, 0.28; 95% CI, 0.25–0.32; p<0.001). Patients with Type 2 MI had a higher burden of cardiovascular comorbidities, including coronary artery disease (38.5%), prior MI (12.5%), and chronic kidney disease (38.9%). Despite higher acuity, 30-day readmission rates were paradoxically lower in the Type 2 MI group (0.9% vs. 1.5%; aOR, 0.64; 95% CI, 0.45–0.92; p=0.01).

Conclusions: In a large, nationally representative cohort, Type 2 MI during DKA hospitalization was independently associated with nearly twofold higher in-hospital mortality and substantially increased resource utilization. These findings highlight the clinical relevance of early recognition and proactive management of myocardial injury in patients with DKA.