Concurrent Diabetic Ketoacidosis and Acute Coronary Syndrome: A Systematic Review of Case Reports

Background: Diabetic ketoacidosis (DKA) and acute coronary syndrome (ACS) represent serious medical emergencies with a complex bidirectional relationship. The clinical presentations and outcomes of these conditions when they co-occur remain incompletely characterized in the literature. We aim to investigate this correlation. Methods: We systematically searched the PubMed, Scopus, and Web of Science databases, using terms related to acute coronary syndrome (including myocardial infarction, unstable angina, STEMI, and NSTEMI) combined with diabetic ketoacidosis terms, from inception to April 2025, for case reports. The CARE checklist was applied to assess the risk of bias in the included reports. Results: Twenty-one case reports met inclusion criteria, describing 11 males and 9 females (one unspecified) with a mean age of 51 years. Patients had both type 1 (42.8%) and type 2 (57.1%) diabetes mellitus. Chest pain was the most common presenting symptom (52.3%), but was absent in nearly half of the cases. Six patients (28.5%) on sodium-glucose cotransporter-2 (SGLT2) inhibitors presented with euglycemic DKA. ST-segment elevation was observed in 61.9% of patients, while five patients had normal coronary arteries despite elevated troponin levels. All patients survived after receiving standard DKA management and appropriate cardiac interventions. Conclusion: This systematic review highlights the importance of maintaining high clinical suspicion for concurrent DKA and ACS, even when typical symptoms such as chest pain or hyperglycemia are absent. We recommend routine cardiac evaluation, including ECG, troponin assessment, and echocardiography, for all DKA patients to ensure early recognition and appropriate management of these potentially life-threatening conditions.