This case involves a 65-year-old woman with cardiovascular risk factors (diabetes and hyperlipidemia) presenting with acute-onset chest pain and diaphoresis. Her ECG shows hyperacute T-waves without ST elevation, a concerning finding suggesting myocardial ischemia. The combination of typical anginal symptoms (chest pain, diaphoresis) with ECG changes in a patient with multiple risk factors strongly suggests acute coronary syndrome (ACS). The hyperacute T-waves specifically point toward early myocardial infarction or severe ischemia, though the absence of ST elevation distinguishes this from a classic STEMI. Other cardiac conditions such as pericarditis, aortic dissection, or stress cardiomyopathy could present similarly but are less likely given the specific ECG findings. Missing information includes vital signs, chest pain characteristics (location, radiation, quality), troponin levels, and prior cardiac history.

Most Likely Diagnoses

1. Non-ST Elevation Myocardial Infarction (NSTEMI)

• Supporting Evidence: Acute chest pain with diaphoresis in a patient with multiple cardiovascular risk factors (diabetes, hyperlipidemia). Hyperacute T-waves are an early sign of myocardial injury before ST elevation develops, representing the initial phase of myocardial infarction.

• Opposing Evidence: Troponin levels are not provided to confirm myocardial injury. Without serial ECGs, we cannot determine if this represents evolving MI versus unstable angina.

2. Unstable Angina

• Supporting Evidence: Acute chest pain with ECG changes in a patient with risk factors for coronary artery disease. Hyperacute T-waves can represent severe ischemia without infarction, which defines unstable angina.

• Opposing Evidence: The presence of hyperacute T-waves often suggests a process that may progress to infarction rather than angina alone. Without troponin measurements, distinguishing from NSTEMI is difficult.

3. Coronary Vasospasm (Prinzmetal's Angina)

• Supporting Evidence: Can present with acute chest pain and transient ECG changes including T-wave abnormalities. Often occurs at rest with diaphoresis, similar to this presentation.

• Opposing Evidence: Typically presents with transient ST elevation rather than isolated hyperacute T-waves. Less common than atherosclerotic ACS in patients with established cardiovascular risk factors.

  
  

Expanded Differential

1. Stress Cardiomyopathy (Takotsubo Syndrome)

• Supporting Evidence: Can present with chest pain, diaphoresis, and ECG changes mimicking ACS. More common in postmenopausal women.

• Opposing Evidence: Typically presents with ST-segment elevation or T-wave inversions rather than hyperacute T-waves. Usually triggered by emotional or physical stress, which is not mentioned in this case.

2. Pericarditis

• Supporting Evidence: Can present with chest pain and ECG changes. Sometimes occurs in patients with metabolic disorders like diabetes.

• Opposing Evidence: Typically presents with diffuse ST elevation and PR depression rather than hyperacute T-waves. Pain characteristics usually differ from typical angina (positional, pleuritic).

3. Esophageal Spasm

• Supporting Evidence: Can cause chest pain that mimics cardiac ischemia. More common in older adults.

• Opposing Evidence: Would not explain the ECG changes with hyperacute T-waves. Diaphoresis is more typical of cardiac rather than esophageal causes.