A 62-year-old man presented with a 3-day history of intermittent episodes of central chest discomfort and associated dyspnea, culminating in a 20-minute episode occurring at rest, with marked diaphoresis and associated anguor animi. He had recently been diagnosed with type 2 diabetes mellitus and was adhering to a diabetic diet. Home blood sugar monitoring had suggested reasonable diabetic control.

Results of physical examination on hospital admission (in the absence of pain) were notable for the presence of an apical fourth heart sound and occasional basal crepitations in the lung fields. An initial electrocardiogram (ECG) was normal, and results of initial biochemical evaluation included normal troponin, electrolyte, and creatine kinase levels, but a blood sugar level of 14 mmol/L.

The patient was admitted to the coronary care unit and treated with 100 mg/day of aspirin, intravenously infused unfractionated heparin, 90 mg of diltiazem (Cardizem, Tiazac) 3 times/ day, and infused nitroglycerin. Acute treatment for hyperglycemia was initiated with subcutaneous insulin, and the patient was also started on 40 mg/day of atorvastatin (Lipitor).

Two hours after admission, the patient experienced another episode of chest pain. Continuous 12-lead ST-segment monitoring revealed that there had been a number of episodes of marked ST-segment depression in the inferolateral leads. Activated partial thromboplastin time was 65 seconds (therapeutic, 60-85 seconds). The blood sugar level was 11.5 mmol/L. A decision was made to perform urgent cardiac catheterization, preceded by administration of clopidogrel (Plavix; 300 mg).

At cardiac catheterization, the left coronary artery was normal, and there was a proximal subtotal eccentric stenosis of a dominant right coronary artery with Thrombolysis in Myocardial Infarction grade 2 flow and visible extensive distal thrombus. The patient was given an additional 300 mg of clopidogrel. Treatment with abciximab (ReoPro) was started; the stenosis was dilated and a stent inserted. An intravenous infusion of insulin was begun.

The postprocedural blood sugar level decreased to 7 mmol/L over 4 hours. Continuous ST-segment monitoring indicated gradual resolution of ischemic episodes over 8 hours postprocedure. The patient was weaned from intravenous infusions after 24 hours, ramipril (Altace; 10 mg/day) was added to the treatment regimen, and the patient was discharged 48 hours after the procedure, remaining asymptomatic over a follow-up period of 6 months.