A 60 year old woman suffering from hypertension secondary to diabetic nephropathy was being followed up in a nephrology clinic. Her leg was amputated four years ago. At her fifth day of admission she had been seen by a cardiologist because of chest discomfort lasting 20 minutes and ST elevations on her electrocardiogram (ECG) (fig 1). Blood pressure was 150/80 mm Hg and heart rate 75 beats/min. A pansystolic murmur graded 3/6 was heard at the apex. Neither gallop sounds nor pulmonary rales were present. She was taken to the coronary care unit; aspirin, heparin, and nitrate were started.

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Laboratory analyses, performed at follow up in the nephrology clinic, were as follows: haemoglobin 94 g/l, packed cell volume 0.29, urea 43.2 mmol/l, creatinine 406.6 µmol/l, sodium 126 mmol/l, potassium 3.5 mmol/l, creatine kinase MB fraction 12 U/l. The latter was in normal limits during the first 24 hours. The ECG before her complaint showed coarse atrial fibrillation without ST change. . . . [Full text of this article]