Differential Diagnoses for Acute Chest Pain and Dyspnea

Based on the presentation of Ms. R.T., the differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • Takotsubo Cardiomyopathy (Stress-Induced Cardiomyopathy): This condition is characterized by transient left ventricular dysfunction, often triggered by intense emotional or physical stress, which fits with the patient's recent news of her spouse's death. The mildly elevated troponin, elevated BNP, and echocardiographic findings of apical hypokinesis support this diagnosis.

• Other Likely Diagnoses

  • Acute Coronary Syndrome (ACS): Although the patient has no prior cardiac history, her family history of myocardial infarction and the presence of risk factors like hypertension make ACS a consideration. The mildly elevated troponin and nonspecific ST-T changes on the EKG contribute to this possibility.
  • Pulmonary Embolism (PE): Despite the lack of pleuritic chest pain or syncope, PE remains a consideration due to the acute onset of dyspnea and the potential for a hypercoagulable state following intense emotional stress. However, the clear lung fields on examination and normal CXR make this less likely.
  • Anxiety-Related Chest Pain: Given the patient's description of being "very anxious" and the timing of the chest pain following stressful news, anxiety could be contributing to or mimicking cardiac symptoms.

• Do Not Miss Diagnoses

  • Aortic Dissection: Although less likely given the lack of classic tearing chest pain radiating to the back and no significant blood pressure differential between arms, aortic dissection is a potentially fatal condition that must be considered in any patient with acute chest pain.
  • Pneumothorax: Despite the clear lung fields on examination, a pneumothorax could present with sudden chest pain and dyspnea. The absence of pleuritic pain and a normal CXR decrease the likelihood but do not rule it out entirely.

• Rare Diagnoses

  • Myopericarditis: Inflammation of the myocardium and pericardium could present with chest pain and elevated troponin. However, the absence of fever, pericardial friction rub, and specific EKG changes makes this less likely.
  • Spontaneous Coronary Artery Dissection (SCAD): A rare cause of ACS, more common in women without traditional cardiovascular risk factors. The presentation could mimic other forms of ACS, but specific diagnostic tests like coronary angiography would be needed to confirm.

Each of these diagnoses is considered based on the combination of the patient's symptoms, past medical history, family history, physical examination findings, and initial diagnostic test results. The justification for each includes the presence or absence of specific clinical features and how well the diagnosis aligns with the patient's overall presentation.