Differential Diagnosis for Acute Onset of Severe Chest Pain

• Single most likely diagnosis:
  • Takotsubo Cardiomyopathy: This condition is characterized by a sudden onset of severe chest pain, often triggered by intense emotional or physical stress, which fits the patient's recent loss of a significant other. The presentation of "crushing" chest pain, positive troponin assays, and reduced ejection fraction with akinesia of the left ventricle, along with normal coronary arteries, strongly supports this diagnosis. The patient's lack of risk factors for coronary artery disease and the absence of significant findings on physical examination also point towards this condition.
• Other Likely diagnoses:
  • Myocarditis: Although less likely given the normal coronary arteries and the specific pattern of left ventricular akinesia, myocarditis could present with chest pain, elevated troponins, and reduced ejection fraction. The recent stress could potentially trigger an autoimmune response leading to myocarditis.
  • Acute Coronary Syndrome with Spontaneous Coronary Artery Dissection (SCAD): Despite the normal appearance of coronaries on cath lab, SCAD could potentially cause acute coronary syndrome. However, the lack of risk factors and the specific echocardiogram findings make this less likely.
• Do Not Miss diagnoses:
  • Aortic Dissection: This is a medical emergency that can present with severe, tearing chest pain that may radiate to the back or shoulders. Although the pain description and radiation pattern do not perfectly match, and the ECG and troponin findings might not typically be the first presentation, aortic dissection is a condition that must be considered due to its high mortality rate if missed.
  • Pulmonary Embolism: While the presentation does not strongly suggest pulmonary embolism, it is a condition that can cause sudden onset of chest pain and must be considered, especially in the context of recent stress and potential immobility, which could increase the risk of venous thromboembolism.
• Rare diagnoses:
  • Stress-induced Hypertrophic Cardiomyopathy: Although rare, stress can potentially unmask or exacerbate hypertrophic cardiomyopathy, leading to acute presentations with chest pain and reduced ejection fraction.
  • Catecholamine-induced Cardiomyopathy: This could be considered in the context of extreme stress leading to a catecholamine surge, causing cardiomyopathy. However, this would be less common and the clinical presentation would need to align closely with this diagnosis.