In a 70‑year‑old man with coronary artery disease, prior percutaneous coronary intervention, insulin‑treated diabetes, hypertension, exertional substernal chest pain not relieved by rest, radiation to the neck, 2 mm ST‑segment depression with T‑wave changes in V1‑V2, and normal initial cardiac enzymes, what is the most likely diagnosis?

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Last updated: February 27, 2026 • View editorial policy

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Unstable Angina

This patient has unstable angina (option B), not stable angina, GERD, or STEMI. The combination of exertional chest pain that is not relieved by rest, ST-segment depression with T-wave changes on ECG, and normal initial cardiac biomarkers in a high-risk patient with known coronary disease defines unstable angina within the spectrum of non-ST-elevation acute coronary syndrome (NSTE-ACS). 1, 2

Why This is Unstable Angina

The key distinguishing feature is that the pain does not resolve with rest, which immediately excludes stable angina (option D). 1 In stable angina, symptoms predictably occur with exertion and reliably resolve within minutes of rest or nitroglycerin. 1 This patient's pain persists despite stopping activity, indicating an acute coronary syndrome. 1

The ECG shows 2 mm ST-segment depression with T-wave changes in V1-V2, which are highly suggestive of acute myocardial ischemia and classify this as NSTE-ACS rather than stable disease. 1 ST-segment depression ≥1 mm in two or more contiguous leads is a reliable electrocardiographic indicator of unstable coronary disease. 1

Normal initial cardiac enzymes distinguish unstable angina from NSTEMI. 1, 2 Both conditions present identically with chest pain and ECG changes, but NSTEMI shows elevated troponin indicating myocardial necrosis, while unstable angina has normal biomarkers despite significant ischemia. 1 The troponin must be repeated at 6-12 hours after symptom onset to definitively exclude NSTEMI, as initial measurements can be falsely negative. 1, 2

Why Not the Other Options

GERD (option A) is excluded by the clinical context and ECG findings. 1 While GERD can cause substernal discomfort, it does not produce 2 mm ST-segment depression or T-wave changes on ECG. 1 The radiation to neck and jaw, exertional trigger, and significant ECG abnormalities in a patient with established coronary disease make a cardiac etiology overwhelmingly likely. 1

STEMI (option C) is ruled out by the absence of persistent ST-segment elevation. 1 This patient has ST-segment depression, not elevation. 2 STEMI requires persistent (>20 minutes) ST-segment elevation reflecting acute total coronary occlusion. 1 ST-segment depression indicates NSTE-ACS, not STEMI. 1, 2

Stable angina (option D) is excluded because the pain does not resolve with rest. 1 Additionally, the presence of ST-segment depression during or after symptoms indicates acute ischemia, not stable disease. 1 Stable angina patients have predictable, brief episodes that resolve promptly with rest or nitroglycerin. 1

High-Risk Features Requiring Urgent Management

This patient has multiple high-risk features that mandate immediate hospitalization and aggressive therapy: 1, 2

  • Prior PCI three years ago indicates established coronary disease with risk of restenosis or progression 1
  • Diabetes mellitus is associated with atypical presentations and worse outcomes in ACS 1
  • ST-segment depression ≥2 mm is a high-risk ECG finding 1, 2
  • Pain not relieved by rest suggests ongoing ischemia 1
  • Age 70 years increases risk 3, 4

Immediate management should include: 1, 2

  • Aspirin 162-325 mg chewed immediately 2
  • Clopidogrel 300-600 mg loading dose (or ticagrelor) 2
  • Low-molecular-weight heparin or unfractionated heparin 2
  • Beta-blocker (blood pressure 140/90 tolerates this) 2
  • Sublingual or IV nitroglycerin for ongoing pain 2
  • Continuous ECG monitoring 2
  • Serial troponin measurements at 6-12 hours 1, 2
  • Coronary angiography within 24-48 hours given the high-risk features 1, 2

Critical Pitfall to Avoid

Do not dismiss this as stable angina simply because the initial troponin is normal. 1 Approximately two-thirds of ischemic episodes in unstable coronary disease are "silent" or atypical, and troponin can remain normal in unstable angina despite significant myocardial ischemia. 1 The combination of rest pain (or pain not relieved by rest), ECG changes, and high-risk features defines unstable angina even with normal biomarkers. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Diagnosis and Management of Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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