Chest pain with raised troponin, ECG changes but normal coronary arteries

Area of Science:

• Cardiology
• Vascular Surgery
• Emergency Medicine

Background:

• Acute coronary syndrome (ACS) is a common cause of chest pain, often presenting with ECG changes and elevated troponin.
• Differential diagnosis for chest pain is broad, requiring thorough investigation beyond initial presentations.

Observation:

• A 65-year-old woman presented with acute chest pain and dyspnea, showing dynamic T wave changes and elevated troponin, initially diagnosed as ACS.
• Coronary angiography revealed normal coronary arteries, prompting further investigation due to persistent symptoms and elevated D-dimers.
• CT pulmonary angiography excluded pulmonary embolism but identified a large ascending aortic aneurysm with a contained leak.

Findings:

• The patient's symptoms were attributed to a contained ascending aortic aneurysm leak, not ACS.
• Initial diagnostic workup for ACS was misleading despite objective cardiac markers.

Implications:

• This case underscores the necessity of comprehensive clinical evaluation and considering alternative diagnoses in chest pain presentations.
• Timely and appropriate investigations, including advanced imaging, are crucial for identifying rare but critical conditions like aortic aneurysms.
• Elevated troponin and ECG abnormalities warrant a broad differential diagnosis, including vascular emergencies beyond acute coronary syndromes.