Differential Diagnosis for 53-year-old Female with Chest Pain

• Single most likely diagnosis
  • Takotsubo cardiomyopathy: This condition is characterized by transient left ventricular dysfunction, often triggered by intense emotional or physical stress, which aligns with the patient's report of high levels of work-related stress. The absence of obstructive coronary artery disease on left heart catheterization (LHC) and the presence of troponin elevation with EKG changes (TWI in leads I, aVL, and V2) support this diagnosis. The improvement with NTG and aspirin does not rule out this condition, as these treatments can provide symptomatic relief.
• Other Likely diagnoses
  • SCAD (Spontaneous Coronary Artery Dissection): Although the LHC did not show obstructive coronary artery disease, SCAD can sometimes be missed on initial imaging, especially if the dissection is not significant enough to cause obstruction at the time of the procedure or if it is located in a distal or small branch. The patient's symptoms and the fact that she is a female with a history of stress and recent cortisone shot (which can affect blood pressure and potentially vascular integrity) make SCAD a plausible consideration.
  • Esophageal spasm or esophageal disorder: The patient's pain is described as severe, sharp, and located in the mid-lower chest, which can be consistent with esophageal pathology, especially given the association with eating. The improvement with NTG could be due to its smooth muscle relaxant properties, which might also relieve esophageal spasm.
• Do Not Miss diagnoses
  • Aortic dissection: Although less likely given the LHC results and the nature of the pain, aortic dissection is a critical diagnosis that must be considered in any patient presenting with severe, sharp chest pain. The fact that the pain radiated to the left arm and was associated with nausea, diaphoresis, and shortness of breath increases the necessity of ruling out this condition.
  • Pulmonary embolism: This condition can present with chest pain, shortness of breath, and can be associated with stress and recent immobilization (if any). The BNP of 22 is not significantly elevated, which makes heart failure less likely, but does not rule out pulmonary embolism.
• Rare diagnoses
  • Pericarditis: The sharp chest pain and EKG changes could suggest pericarditis, although the pattern of TWI is not typical for pericarditis, and the significant troponin elevation is more suggestive of myocardial injury.
  • Cocaine-induced cardiomyopathy: Although the patient reports only occasional alcohol use and does not mention cocaine, this diagnosis should be considered in any patient with unexplained cardiomyopathy or myocardial infarction pattern without obstructive coronary disease, given the potential for underreporting of substance use.