Differential diagnosis of acute coronary syndrome without ST-segment elevation in a middle-aged patient

Acute Coronary Syndrome (ACS) is an initial diagnosis, which is transformed into the diagnosis of “myocardial infarction”, “unstable angina” or other diagnosis during the diagnostic process. If a patient meets the criteria for myocardial infarction (according to the Fourth Universal Definition of Myocardial Infarction), in the presence of atherothrombosis in the infarct-related coronary artery, Type 1 myocardial infarction is diagnosed. In most of the remaining cases Type 2 myocardial infarction is diagnosed. Acute myocardial injury due to various conditions is separately classified. In the presented case, a 54-year-old patient with a history of arterial hypertension and diabetes mellitus, not adherent to treatment and suffering from obesity, a smoker, was hospitalized with typical new-onset angina pectoris and ischemic changes on the ECG, by ambulance, with the initial diagnosis of “ACS without ST-segment elevation”. The diagnosis changed several times during the examination: “ACS without ST-segment elevation”, “CAD: myocardial infarction without ST-segment elevation”, “Myocardial infarction with non-obstructive coronary arteries (MINOCA)”, “Severe calcified aortic stenosis. Anemia. Type 2 myocardial infarction”. The peculiarity of this case is the debut of high-gradient aortic stenosis in a middle-aged man with clinical manifestations of ACS and high blood troponin level. Causes of severe aortic stenosis manifestation as myocardial infarction with elevation of cardiac-specific troponin in the blood, despite intact coronary vessels, are discussed in this article. The differential diagnosis of myocardial injury is discussed, as the correct diagnostic judgment directly determines the patient’s management strategy.

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