Differential Diagnosis for a 76-year-old Male with Chest Pain

The patient's presentation includes retrosternal chest pain with exertion relieved by rest, an S4 heart sound, T wave inversion in leads V2-V5 on ECG, and elevated Troponin levels. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • NSTEMI (Non-ST-Elevation Myocardial Infarction): The patient's symptoms of exertional chest pain relieved by rest, along with ECG changes (T wave inversion in leads V2-V5) and elevated Troponin levels, are highly suggestive of NSTEMI. The presence of an S4 heart sound can indicate decreased compliance of the left ventricle, often seen in conditions like ischemia.

• Other Likely Diagnoses

  • Unstable Angina: This condition presents similarly to NSTEMI but without the elevation of Troponin levels. However, given the patient's elevated Troponin, this is less likely but still a consideration due to the similar clinical presentation.
  • Stable Angina: Although the patient's symptoms are typical for stable angina (exertional chest pain relieved by rest), the presence of T wave inversion and elevated Troponin levels suggests a more acute process.

• Do Not Miss Diagnoses

  • STEMI (ST-Elevation Myocardial Infarction): Although the ECG description does not mention ST elevation, which is the hallmark of STEMI, it's crucial to ensure that no ST elevation is present in any lead, as STEMI is a medical emergency requiring immediate intervention.
  • Aortic Dissection: This condition can present with chest pain and can be a cause of myocardial infarction if the dissection involves the coronary arteries. The pain is often described as tearing and can be atypical, but it's a critical diagnosis not to miss due to its high mortality.

• Rare Diagnoses

  • Coronary Artery Spasm (Prinzmetal’s Angina): This condition involves transient coronary artery spasm and can cause chest pain at rest. While it's less likely given the exertional nature of the pain, it's a rare cause of myocardial infarction and should be considered if other diagnoses are ruled out.
  • Myopericarditis: Inflammation of the myocardium and pericardium can cause chest pain and ECG changes, including T wave inversion. However, the clinical context and elevated Troponin levels make this a less likely diagnosis in this scenario.