CAR-4. Chest pain and increased Troponin: acute coronary syndrome?

A 31-year-old male with past medical history of infective endocarditis and aortic valve replacement presented from an outside hospital with chest pain for 1 day, EKG changes and rise in his cardiac enzymes. He presented there with sharp chest pain, refractory to sublingual nitroglycerin and intravenous Dilaudid and difficulty breathing. EKG showed T wave inversions inferolaterally. His second set of Troponin-I was positive. He was transferred to our hospital for further management. On exam, a systolic murmur was noted. His Troponin-T at our hospital was elevated at 0.5. Transesophageal echocardiogram showed possible evidence of myocardial infarction with wall motion abnormalities consistent with circumflex/right coronary artery disease and there was no evidence of endocarditis or dissection. Cardiac catheterization revealed angiographically normal coronary arteries. His picture was felt to be most consistent with pericarditis, possibly Dressler's syndrome. Treatment with NSAIDs lead to complete resolution of the pain. Troponin is well recognized as a highly sensitive and specific marker for myocardial injury in acute coronary syndromes (ACS). In our patient. Troponin-T was elevated although there was no evidence of an ACS. The elevation could be attributed to pericarditis. A recent study of 14 patients with acute pericarditis showed increased levels of Troponin I in 10 patients. An earlier retrospective study revealed Troponin I elevation in 49% of patients with acute pericarditis. The exact mechanism by which troponin is released into circulation in pericarditis is not known. It has been postulated that this could be secondary to concomitant inflammatory and degenerative changes in the superficial myocardium. Pericarditis should be considered in the differential diagnosis in patients with Troponin elevation, especially in the young patient with atypical chest pain. Troponin is often elevated in acute pericarditis, and by itself does not help in the differential diagnosis between an ACS and acute pericarditis

Arun Kalyanasundaram, MD, Michael Foltzer, MD, Robert Gotoff, MD, and Louis A. Nassef, MD.