Differential Diagnosis for Acute Onset of Severe Chest Pain
- Single most likely diagnosis
- Myocarditis: Given the acute onset of severe chest pain, positive troponin assays, and normal coronary arteries on cath lab, myocarditis is a strong consideration. The recent stressful event could be a trigger, and the mild non-specific precordial ST changes on ECG also support this diagnosis.
- Other Likely diagnoses
- Acute Pericarditis: The nature of the chest pain (sharp, radiating to the shoulder) and the ECG changes could suggest pericarditis. However, the positive troponin assays and the lack of a pericardial friction rub on physical examination make this less likely than myocarditis.
- Pulmonary Embolism (PE) with minimal symptoms: Although the patient does not have typical risk factors for PE, the acute onset of chest pain and the recent stressful event (which could be a trigger for immobility) make this a consideration. However, the lack of respiratory symptoms and the normal physical examination make this less likely.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Aortic Dissection: This is a life-threatening condition that requires immediate attention. Although the patient's presentation (no tearing or ripping sensation, no significant blood pressure difference between arms) and the normal physical examination make this less likely, it cannot be entirely ruled out without further imaging (e.g., CT angiography).
- Coronary Artery Dissection or Spontaneous Coronary Artery Dissection (SCAD): Although the cath lab revealed normal coronaries, SCAD can sometimes be missed on initial angiography. This condition is more common in women but can occur in men, especially with a recent stressful event.
- Rare diagnoses
- Takotsubo Cardiomyopathy: Given the recent stressful event and the positive troponin assays, this condition (also known as "stress cardiomyopathy") could be considered. However, the normal coronary arteries and the lack of typical echocardiographic findings make this less likely.
- Esophageal Rupture or Esophagitis: These conditions can cause severe chest pain but are less likely given the patient's presentation and the positive troponin assays.