Abstract Body: Background: Metabolic derangements such as diabetic ketoacidosis can produce electrocardiographic changes that mimic ST-elevation myocardial infarction. Recognition of non-ischemic causes of ST elevation is critical to avoid unnecessary invasive procedures.

Research question: Severe metabolic disturbances associated with diabetic ketoacidosis and hyperkalemia may produce electrocardiographic patterns that mimic acute myocardial infarction despite the absence of coronary occlusion.

Goals: The goal of this study is to highlight a case of diabetic ketoacidosis–associated hyperkalemia presenting with ST-segment elevation mimicking myocardial infarction and to emphasize clinical features that aid in distinguishing pseudoinfarction patterns from true coronary occlusion.

Methods: Clinical data were reviewed including presenting symptoms, laboratory findings, serial electrocardiograms, cardiac biomarkers, and transthoracic echocardiography to evaluate the cause of ST-segment elevation.

Results: A 56-year-old man with a history of type 2 diabetes mellitus and hypertension presented with several days of nausea and vomiting and was transferred for concern of ST-elevation myocardial infarction and diabetic ketoacidosis. Laboratory evaluation revealed severe metabolic acidosis, hyperkalemia with a potassium level of 7.0 mmol/L, and acute kidney injury. Electrocardiogram at the referring facility demonstrated ST-segment elevation in the precordial leads with reciprocal changes in the inferior leads. The patient denied chest pain. High-sensitivity troponin peaked at 453 ng/L. Transthoracic echocardiogram demonstrated preserved left ventricular systolic function without regional wall motion abnormalities. Serial electrocardiograms showed resolution of ST-segment changes with correction of hyperkalemia and metabolic acidosis.

Conclusion: Diabetic ketoacidosis–associated hyperkalemia can produce a pseudoinfarction electrocardiographic pattern. Recognition of this entity is essential to prevent unnecessary invasive procedures and to guide appropriate metabolic management.