Acute coronary syndrome and diabetic keto acidosis: the chicken or the egg?

We sought to describe two cases of diabetic ketoacidosis (DKA) with elevated troponin. The association of DKA with myocardial infarction (MI) is very frequent. We therefore decide to look deeply in the potential mechanisms behind this strong relationship. We did review the potential role of severe acidosis, intracellular calcium, the counter-regulatory hormones and the potential of the free fatty acid release. Those two conditions can trigger each other and it is often difficult to know which condition appear first. Ultimately, it stands to reason that the message for the clinician should be that a troponin elevation in a DKA patient should always be considered as a coronary abnormality until proven otherwise.