Differential Diagnosis for Central Chest Pain with Negative Troponin and ST Inversion
Single Most Likely Diagnosis
- Acute Coronary Syndrome (ACS) with Non-ST Elevation Myocardial Infarction (NSTEMI): Although troponin is negative, it may be too early to detect, or the level of myocardial damage might not be sufficient to elevate troponin levels. ST inversion in multiple leads suggests ischemia.
Other Likely Diagnoses
- Pericarditis: The presence of ST inversion in leads I, II, aVF, V4-V6 could indicate pericarditis, especially if there's associated chest pain that improves with sitting up and leaning forward.
- Pulmonary Embolism (PE): Central chest pain and ST changes can be seen in PE, particularly if there's associated hypoxia or tachycardia.
- Acute Aortic Dissection: Although less common, the central nature of the chest pain and the presence of ST inversion could suggest an aortic dissection, especially if there's a significant difference in blood pressure between arms.
Do Not Miss Diagnoses
- Myocardial Infarction with Normal or Minimally Elevated Troponin: Some MIs, especially those involving the right ventricle or smaller areas of the myocardium, might not significantly elevate troponin levels initially.
- Aortic Dissection: Given the potential for rapid progression and high mortality, it's crucial not to miss this diagnosis, even though it's less likely.
- Pulmonary Embolism with Cardiac Involvement: A large PE can cause right ventricular strain, leading to ST changes and chest pain.
Rare Diagnoses
- Takotsubo Cardiomyopathy: Also known as stress cardiomyopathy, this condition can mimic ACS with ST changes and chest pain but is caused by extreme emotional or physical stress.
- Myopericarditis: An inflammation of both the myocardium and pericardium, which can present with chest pain and ST changes.
- Coronary Artery Spasm: Also known as variant angina, this condition involves transient coronary artery spasm leading to chest pain and ischemic ECG changes.