JIACM 2002; 3(4): 383-6

IMAGES IN CLINICAL MEDICINE

Complete Heart Block, Cardiovascular Autonomic Neuropathy

and Triple Vessel Disease in Type-2 Diabetes Mellitus with
Insulin Resistance
S Dwivedi*, SR Kabra*, S Rajput*

A 54- year-old sedentary lady presented with a

history of sudden onset dizziness (that used to
increase on standing), fatigue, and atypical mild
chest pain of few hours duration. She was a known
case of type-2 diabetes mellitus (since twelve years)
with poor glycaemic control, chronic stable angina
for six years, and long standing dyslipidaemia.
She was detected hypertensive a month ago. ECG
done at rest at that time suggests myocardial
ischaemia with tachycardia (Fig. 1). Detailed family
history revealed that her mother was a diabetic
and had died of sudden cardiac death at the age
of 54 years. Among her siblings, two brothers and
a sister were also diabetic. Two elder daughters
among her three children were obese (Fig. 2). On
examination, her pulse rate was 42 per minute,
blood pressure 90/60 mmHg, body mass index
26.4 kg/m 2 , and waist hip ratio 0.99.
Cardiovascular examination revealed a diffuse
apex shifted down and out with soft first heart
sound and a pansystolic grade 3/6 murmur at
the apex. A clinical diagnosis of acute coronary
event with? complete heart block (CHB) was made
and an urgent ECG was done which suggested
an acute postero-inferior wall MI and ischaemic
changes in anteroseptal and lateral leads. In Fig. 1.
addition, there was a CHB (Fig. 3). Her subsequent
ECG had a junctional rhythm with extensive and dyslipidaemia. She was referred for coronary
anterior and lateral wall ischaemia, in addition to angiography, which revealed triple vessel disease.
an inferior wall MI (Fig. 4). Her last ECG recording She was then subjected to coronary artery bypass
was suggestive of an inferior wall MI with variable grafting (CABG). Her recovery was uneventful and
first-to-second degree AV nodal block (Fig. 5). she is currently asymptomatic.
The above ECG findings were suggestive of a
multi-vessel disease in the background of long Comments
standing type-2 diabetes mellitus, hypertension, This case underscores risk of acquiring triple
*Department of Medicine
vessel disease that may be severe enough to
Preventive Cardiology Division, cause complications such as CHB in patients with
UCMS and GTB Hospital, Delhi-110 095. uncontrolled type-2 diabetes mellitus1. CHB and
Fig. 2 : PEDIGREE (
arrow indicates the index case).

other conduction abnormalities are common

accompaniments of inferior wall MI as the blood
supply to the conducting system and inferior wall
of the heart is through a common right coronary
artery2. Further, diabetics are known to have an
increased incidence of sudden cardiac death
(refer to the patient’s mother in Fig. 2). Our case
was diabetic and had central obesity indicating
insulin resistance. Long standing diabetes
mellitus with insulin resistance is associated with
various cardiovascular risk factors (Table I)3. This
case had multiple cardiovascular risk factors
enumerated in Table I. However, we could not Fig. 3.
assess for PIA-1 activity. She had
echocardiographic evidence of ischaemic mitral only an increased risk for the development of
regurgitation (IMR) which itself is a poor cardiovascular disease, but also poorer
prognostic marker for increased cardiovascular prognosis for these individuals once they develop
events. Another aspect, which needs elaboration apparent CAD. The ECG evidence of resting
in long standing diabetes, is cardiovascular tachycardia about a month ago (Fig. 1), dizziness
autonomic neuropathy (CAN), which confers not on standing, and subsequent development of

384 Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 4
October-December 2002
Fig. 4.

CHB, then a grade 2 AV block subsequently

Fig. 5.
changing to variable block alongwith inferior wall
MI (Fig. 3-5) in the background of long standing
Table II : Mechanism for increased mortality
type-2 DM suggests the presence of CAN. Such
in diabetes with cardiovascular autonomic
patients are more liable to have increased
neuropathy (CAN).
mortality (Table II)4. Development of CHB and
variable AV nodal blocks warrants pacing and 1. Ventricular tachycardia
early revascularisation to ensure adequate 2. Silent myocardial ischaemia
oxygen and blood supply to the myocardium. 3. Impaired coronary vasomotor regulation
4. Increased resting heart rate
Table I : Cardiovascular risk factors associated
5. Absent or blunted rate variablity
with insulin resistance.
6. QT interval abnormalities
1. Hypertension
QTC prolongation
2. Abdominal obesity

Increased QTC dispersion
3. Dyslipidaemia
(Aronson and Johnstone, 2001)4.

Increased VLDL-TG

Decreased HDL The pedigree tree of this patient also deserves

Small, dense atherogenic LDL particles a special mention. It is observed that she has a

Post-prandial lipaemia strong family history of type-2 DM, CAD, and
4. Elevated plasminogen activator inhibitor-1 obesity, which again is a strong cardiovascular
(PAI-1). risk factor. Patients with such a strong family
(Aronson and Johnstone, 2001)3. history of multiple risk factors should be

Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 4
October-December 2002 385
managed aggresively for hyperglycaemia,
dyslipidaemia, and hypertension (NCEP-ATP III
guidelines). All efforts should be made to control
and treat modifiable risk factors. As regards her
progeny (Fig. 2), they need to be screened for
the presence of diabetes, dyslipidaemia, and
other accompaniments of insulin resistance
syndrome. In case they have any one of above
abnormalities, that is, hyperglycaemia,
dyslipidaemia, elevated Lp(a) etc., though
asymptomatic, they ought to be treated
aggressively at young age itself.
References
1. Spener B King III. Textbook of Coronary Arteriography
and Angioplasty. 1985; 368-9.
386 Journal, Indian Academy of Clinical Medicine
2. Goldman MJ. Disturbances of atrioventricular cnduction.
In: Gldman MJ ed. Principles of Clinical
Electrocardiography, 9th ed. Japan, Lange Medical
Publications, Maruzen Company, 1976; 233.
3. Aronson D, Johnstone MT. Coronary artery disease in
diabetes. In: Johnstone MT, Veves A ed. Diabetes and
Cardiovascular Disease, 1st ed. New Jersey, Humana
Press, 2001; 250.
4. Aronson D, Johnstone MT. Coronary artery disease in
diabetes. In: Johnstone MT, Veves A ed. Diabetes and
Cardiovascular Disease, 1st ed. New Jersey, Humana
Press, 2001; 266-8.
5. Third Report of the Joint National Cholesterol Education
Program. Expert panel on Detection, Evaluation and
Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III); National Institute of Heart, Lung and
Blood Institute. National Institute of Health Publication
2001; 1: 3670.

Vol. 3, No. 4
October-December 2002