Differential Diagnosis

• Single most likely diagnosis
  • Acute Coronary Syndrome (ACS) - Myocardial Infarction (MI): The patient's history of chest tightness and shoulder pain similar to his prior NSTEMI, elevated troponin levels, and recent lapse in prasugrel therapy (an antiplatelet medication) make ACS-MI the most likely diagnosis. The patient's past medical history of CAD, NSTEMI, and PCI with stent placement also supports this diagnosis.
• Other Likely diagnoses
  • Stent Thrombosis: Given the patient's history of stent placement and recent discontinuation of prasugrel, stent thrombosis is a possible diagnosis. The patient's symptoms and elevated troponin levels are consistent with this condition.
  • Unstable Angina: Although the patient's troponin levels are elevated, indicating myocardial damage, unstable angina is still a possible diagnosis, especially if the patient's symptoms are due to a new blockage or worsening of existing coronary artery disease.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Aortic Dissection: Although less likely, aortic dissection is a life-threatening condition that can present with chest pain and should be considered, especially in patients with hypertension (BP 185/83 mmHg).
  • Pulmonary Embolism (PE): Although the patient's symptoms are more consistent with cardiac disease, PE can present with chest pain and should be considered, especially in patients with risk factors for thromboembolism.
• Rare diagnoses
  • Spontaneous Coronary Artery Dissection (SCAD): This is a rare condition that can cause myocardial infarction, especially in younger patients, but can also occur in older patients.
  • Coronary Artery Vasospasm: This is a rare condition that can cause chest pain and myocardial infarction, especially in patients with a history of coronary artery disease.