Chest Pain at Rest With Unremarkable ECG and Cardiac Enzymes: Case Study Emphasising the Importance of Clinical Suspicion in the Diagnosis of Coronary Artery Disease

Abstract

Background: Coronary artery disease (CAD), primarily caused by atherosclerosis, is a leading cause of death, presenting as angina or myocardial infarction. Advances in cardiac imaging, angiography, and procedures like percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery have improved early detection and management of this condition. This report presents the case of a man who experienced worsening exertional chest pain and discomfort while at rest.

Case report: A 66-year-old man with a history of neurogenic syncope and asthma presented at the same-day emergency care (SDEC) unit with worsening exertional chest pain and discomfort whilst at rest. Despite normal ECG and cardiac enzyme results, further cardiac computed tomography angiography (CTCA) revealed significant CAD with moderate stenosis in the right coronary artery (RCA) and severe stenosis at the left anterior descending artery (LAD) bifurcation, leading to CABG surgery. Echocardiography showed a left ventricular ejection fraction of 50-54% with mid-inferior and basal to mid-inferoseptal hypokinesia. The cardiology-cardiothoracic multidisciplinary team concluded that CABG surgery would provide the most durable long-term outcome.

Conclusion: This case demonstrates the high importance of clinical suspicion of CAD despite normal initial investigations in the early identification and timely investigation as well as the role multidisciplinary teams and CABG can play in the timely management of complex CAD, ultimately leading to improved patient outcomes.

Keywords: Coronary artery disease; cardiac computed tomography angiography; cardiac rehabilitation; coronary artery bypass graft (CABG); differential diagnosis; major adverse cardiovascular events (MACE); non-ST-elevation myocardial infarction (NSTEMI); percutaneous coronary intervention (PCI); shortness of breath; unstable angina.

Figure 1

Angiographic images illustrating atherosclerotic lesions in the coronary arteries. A) 60% stenosis in proximal right coronary artery (RCA), non-flow limiting disease. 40% stenosis in mid RCA. B) Severe bifurcation disease in the left anterior descending artery (LAD). 80% stenosis in proximal mid LAD. 55% stenosis in distal mid LAD. 35% stenosis in proximal distal LAD. The left circumflex artery (LCx) is normal. C) Anterior view of coronary arteries demonstrating atherosclerosis.