Differential Diagnosis for Elevated Troponin without Chest Pain

Elevated troponin levels are commonly associated with myocardial infarction (MI), but the absence of chest pain can broaden the differential diagnosis. Here's a categorized approach to consider:

• Single Most Likely Diagnosis

  • Myocardial infarction (MI) without typical symptoms: Some patients, especially those with diabetes, women, or the elderly, may experience MI without the classic symptom of chest pain. Instead, they might present with shortness of breath, fatigue, or other atypical symptoms.

• Other Likely Diagnoses

  • Pulmonary embolism (PE): Troponin can be elevated in the setting of a large PE due to the strain on the right ventricle.
  • Heart failure: Both acute and chronic heart failure can lead to elevated troponin levels due to myocardial strain.
  • Myocarditis: Inflammation of the heart muscle can cause troponin elevation and may not always present with chest pain.
  • Cardiac contusion: Trauma to the chest can cause myocardial injury and elevated troponin without typical chest pain symptoms.

• Do Not Miss Diagnoses

  • Aortic dissection: Although it often presents with severe, tearing chest pain, some cases may have atypical presentations, including no chest pain, making it crucial not to miss this diagnosis.
  • Cardiac tamponade: This condition, characterized by fluid accumulation in the pericardial sac, can lead to cardiac compression and elevated troponin. It may not always present with chest pain.
  • Severe pulmonary hypertension: Right ventricular strain from severe pulmonary hypertension can lead to elevated troponin levels.

• Rare Diagnoses

  • Takotsubo cardiomyopathy: Also known as "stress cardiomyopathy," this condition can mimic MI on presentation but is caused by extreme emotional or physical stress.
  • Cardiac sarcoidosis: Inflammation from sarcoidosis affecting the heart can lead to elevated troponin levels.
  • Hypokalemia or other severe electrolyte imbalances: These can cause myocardial injury and elevated troponin in rare cases.
  • Infiltrative cardiomyopathies (e.g., amyloidosis): These rare conditions can cause myocardial injury and elevated troponin without typical chest pain symptoms.

Each of these diagnoses requires careful consideration of the patient's clinical presentation, laboratory results, and imaging studies to accurately diagnose the cause of elevated troponin without chest pain.