A Case of Euglycemic Diabetic Ketoacidosis: SGLT2 Inhibitor Complication Triggering Acute Coronary Syndrome and Cardiac Arrest Post Coronary Artery Bypass Grafting (CABG)
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are widely used in diabetes mellitus (DM) and cardiovascular disease for their glycemic and cardioprotective benefits. However, they carry an uncommon risk of euglycemic diabetic ketoacidosis (EDKA), a form of DKA with near-normal blood glucose. This complication is especially perilous in perioperative settings, and the incidence and outcomes of EDKA in cardiovascular patients have not been robustly quantified. Hence, we present a case of an elderly diabetic patient who developed EDKA on postoperative day (POD) 5 after elective coronary artery bypass grafting (CABG), which precipitated an acute coronary syndrome (ACS) and cardiac arrest. A 79-year-old male with insulin-dependent type 2 DM (on SGLT2i therapy, empagliflozin 10 mg daily) underwent uncomplicated CABG for multi-vessel coronary disease. His SGLT2i therapy was continued until the day of surgery (no preoperative washout). On POD 5, he developed high anion gap metabolic acidosis with normal glycemia (pH=7.1, pCO₂=19 mmHg, bicarbonate (HCO₃⁻)=9 mEq/L, anion gap 26.4 mEq/L). Other causes of high-anion-gap metabolic acidosis were excluded (serum lactate 1.8 mmol/L, afebrile with normal WBC, stable renal and liver function). These findings confirmed EDKA. Despite prompt insulin and fluid therapy, the patient acutely developed chest pain and hemodynamic collapse. Emergent angiography revealed a critical stenosis of the left internal mammary artery (LIMA)-to-left anterior…
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