Determining the Cause
a. EKG: Indeterminate
b. Transthoracic Echocardiography: Normal Wall motion*
Differential Diagnosis
In a patient with chest pain, an indeterminate (nondiagnostic) EKG and a normal echocardiogram with preserved wall motion significantly narrow the differential diagnosis.
This could mean:
Non-specific ST–T wave changes
Poor baseline (artifact, LBBB, LVH, paced rhythm)
No clear ischemic or diagnostic pattern
So, we can’t yet confirm or exclude acute coronary syndrome (ACS) from the EKG alone.
A normal echocardiogram argues against ongoing ischemia or infarction, since regional wall motion abnormalities (RWMAs) appear within minutes of significant myocardial ischemia.
Therefore:
Active myocardial infarction (STEMI, large NSTEMI) is unlikely.
Unstable angina or transient ischemia remains possible (since echo can normalize once ischemia resolves).
Gastroesophageal reflux disease (GERD) – burning, postprandial, relieved by antacids.
Esophageal spasm – can mimic angina; may respond to nitrates.
Peptic ulcer disease or gastritis.
Biliary colic / cholecystitis – RUQ or epigastric pain radiating to back or shoulder.
Musculoskeletal pain / costochondritis – reproducible with palpation or movement.
Pleuritic pain – from pneumonia, pulmonary embolism, or pericarditis.
Anxiety / panic disorder.
Pericarditis – pleuritic, positional pain; normal wall motion; EKG may be nonspecific early.
Aortic dissection – severe, tearing pain; may have normal echo unless dissection involves root.
Microvascular angina (cardiac syndrome X) – normal epicardial coronaries, normal echo, abnormal stress testing.
Takotsubo (stress) cardiomyopathy – early echo may be normal before wall motion changes appear (rare).
Early or intermittent ischemia (unstable angina) – if pain resolves, wall motion can normalize.
Pulmonary embolism (PE) – may cause chest pain and nonspecific EKG changes; echo may be normal unless significant right heart strain.
Pneumothorax or pneumonia – pleuritic pain, abnormal lung exam.
To clarify diagnosis:
Serial cardiac enzymes (troponins) – rule out NSTEMI.
Repeat EKGs during pain and after pain subsides.
Stress test or CT coronary angiogram if troponins negative but suspicion for CAD remains.
Chest X-ray – rule out pulmonary causes.
GI evaluation if symptoms suggest reflux or spasm.
| Likely Categories | Key Clues | Echo Finding |
|---|---|---|
| Unstable angina | Transient pain, risk factors | Normal between episodes |
| GERD / Esophageal spasm | Postprandial, burning, antacid response | Normal |
| Musculoskeletal | Reproducible tenderness | Normal |
| Pericarditis | Pleuritic, positional, friction rub | Normal LV function |
| PE | Dyspnea, pleuritic pain, risk factors | Normal or mild RV strain |
| Anxiety / panic attack | Hyperventilation, normal vitals | Normal |