Differential Diagnosis for Diabetic Lady with Chest Pain and Hypotension

• Single most likely diagnosis

  • Inferior Myocardial Infarction (MI) with Right Ventricular (RV) involvement: The presentation of chest pain with ECG changes suggestive of an inferior MI, combined with hypotension and bradycardia, is highly suggestive of an inferior MI with possible RV involvement. The RV infarct can lead to hypotension and bradycardia due to its effect on ventricular filling and cardiac output.

• Other Likely diagnoses

  • Cardiogenic Shock due to Left Ventricular Failure: Although the ECG suggests an inferior MI, left ventricular dysfunction leading to cardiogenic shock could also present with hypotension. However, the bradycardia might be less common in this scenario.
  • Diabetic Cardiomyopathy with Acute Decompensation: Diabetes can lead to a specific form of cardiomyopathy that might present with heart failure symptoms, including hypotension. However, the acute onset of chest pain would be more suggestive of an ischemic event.
  • Sepsis: Although less directly related to the chest pain, a diabetic patient could be at risk for infections that lead to sepsis, presenting with hypotension. The bradycardia might be less typical, and other signs of infection would be expected.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Pulmonary Embolism (PE): A PE could present with chest pain and hypotension, and although the ECG suggests an MI, a large PE could have similar ECG findings (e.g., right bundle branch block, T-wave inversions in the right precordial leads). Bradycardia is less common but can occur.
  • Aortic Dissection: This is a life-threatening condition that could present with chest pain and hypotension. The pain is often described as tearing and can radiate to the back. Bradycardia is not typical but could occur in certain scenarios, such as involvement of the aortic root affecting the heart's electrical conduction.
  • Cardiac Tamponade: Although less likely given the presentation, cardiac tamponade could result from an MI (free wall rupture) and present with hypotension and possibly bradycardia due to increased vagal tone.

• Rare diagnoses

  • Stress-induced (Takotsubo) Cardiomyopathy: This condition, often triggered by intense emotional or physical stress, can mimic MI on ECG and echocardiography but without evidence of coronary artery occlusion. It might present with hypotension but is less likely to cause bradycardia.
  • Phaeochromocytoma: A rare tumor of the adrenal gland that could cause episodic hypertension but also hypotension during certain phases of the disease, along with tachycardia more commonly than bradycardia. However, it's an important consideration in the differential diagnosis of unexplained hypotension and cardiac symptoms.