A 55-year-old man presents with chest pain at rest. ECG during pain shows transient ST-segment elevation in leads V1–V4 that resolves completely when the pain stops. Troponin levels are normal on two sets taken 6 hours apart. He is a smoker but has no other conventional risk factors. Coronary angiography reveals no obstructive coronary artery disease. What is the MOST likely diagnosis?
- A Type 1 NSTEMI with spontaneous reperfusion
- B Takotsubo (stress) cardiomyopathy
- C Pericarditis with early repolarization pattern
- D Prinzmetal (variant) angina due to coronary vasospasm ✓
Explanation
Prinzmetal angina is characterized by transient ST elevation at rest that resolves spontaneously, normal troponin (ischemia is brief and does not cause necrosis), and normal or near-normal coronary arteries on angiography due to focal coronary spasm. Smoking is the major risk factor. NSTEMI requires troponin elevation by definition. Takotsubo causes a distinctive apical ballooning on echocardiography and is usually triggered by emotional or physical stress in post-menopausal women, with wall-motion abnormalities. Pericarditis produces diffuse saddle-shaped ST elevation (not focal lead-specific transient changes) and does not cause angiographically documented spasm.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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