Differential Diagnosis for Chest Pain and Dyspnea with ST Elevation but Negative Troponin

• Single Most Likely Diagnosis

  • Acute Pericarditis: This condition often presents with chest pain and ST elevation on ECG but can have negative troponin levels, especially if the myocardium is not significantly involved. The pain is typically sharp and improves with sitting up and leaning forward.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): While PE can cause ST elevation, it's more commonly associated with other ECG findings. However, it's a critical diagnosis to consider in patients with dyspnea and chest pain, as it can lead to significant morbidity and mortality if not promptly treated.
  • Myopericarditis: This condition involves both the myocardium and pericardium, potentially leading to ST elevation and negative or mildly elevated troponin levels, depending on the extent of myocardial involvement.
  • Early Repolarization: A benign condition that can mimic ST elevation on ECG, often seen in healthy individuals. However, it's essential to differentiate it from acute coronary syndromes or pericarditis.

• Do Not Miss Diagnoses

  • Acute Coronary Syndrome (ACS) with Early Presentation: Some patients with ACS, especially those presenting very early after symptom onset, might have negative troponin levels. It's crucial to monitor these patients closely and repeat troponin tests, as missing ACS can be fatal.
  • Aortic Dissection: Although less common, aortic dissection can cause chest pain and, in some cases, ST elevation if the dissection involves the coronary arteries. It's a medical emergency that requires immediate intervention.

• Rare Diagnoses

  • Hypokalemic or Hyperkalemic Cardiomyopathy: Electrolyte imbalances can cause ST elevation on ECG. While not the first consideration, they are important to rule out, especially in patients with known electrolyte disturbances.
  • Takotsubo Cardiomyopathy: Also known as "stress cardiomyopathy," this condition can mimic acute coronary syndrome with ST elevation but typically has a distinct pattern on echocardiography and often lacks significant troponin elevation.
  • Brugada Syndrome: A genetic disorder that can cause ST elevation in the right precordial leads and is associated with an increased risk of sudden cardiac death. It's a rare but important diagnosis to consider in patients with unexplained ST elevation.