A man in his 60s with a history of nonobstructive coronary artery disease (CAD) presented to the emergency department with sudden-onset, nonradiating epigastric pain. The pain began after dinner and was not associated with nausea, vomiting, chest pain, or shortness of breath. On examination, he had epigastric tenderness and a 20 mm Hg interarm difference in systolic blood pressure. Laboratory evaluation revealed aspartate transaminase levels of 274 U/L (reference range, 17-42 U/L), alanine transaminase levels of 184 U/L (reference range, 12-60 U/L) and troponin levels of 0.07 ng/mL (reference range, <0.05 ng/mL). (To convert aspartate transaminase and alanine transaminase to microkatals per liter, multiply by 0.0167; to convert troponin to micrograms per liter, multiply by 1.) Complete blood cell count, creatinine, alkaline phosphatase, and total bilirubin levels were all within normal limits. The electrocardiogram (ECG) and chest radiograph findings were unremarkable. Computed tomography of the chest, abdomen, and pelvis showed no evidence of aortic dissection but demonstrated cholelithiasis, pericholecystic fluid, and gallbladder wall thickening. Ultrasonography of the abdomen confirmed these findings.
Judson TJ, Beach LY, Soni K. The Troponin Cascade: A Teachable Moment. JAMA Intern Med. 2017;177(8):1193–1194. doi:https://doi.org/10.1001/jamainternmed.2017.1804
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