Transient ST-segment elevations with normal troponin are most characteristic of which condition?

• A. Prinzmetal's angina
• B. NSTEMI
• C. Pericarditis
• D. Aortic stenosis

Answer: (A)

Transient ST-segment elevations with normal troponin point to vasospastic angina, also known as Prinzmetal angina. The underlying issue is a temporary coronary artery spasm that briefly reduces blood flow enough to cause transmural ischemia during the episode, which shows up on the ECG as ST elevations in the affected territory. Because the episode is reversible and there isn’t lasting myocardial injury, troponin remains normal. Episodes often occur at rest, can wake patients at night, and tend to respond to nitrates and calcium channel blockers.

In contrast, a troponin rise would be expected with true myocardial infarction (NSTEMI or STEMI) due to irreversible injury. Pericarditis can also show ST elevations, but they are typically diffuse and often accompanied by chest pain that is relieved by leaning forward, and troponin can be elevated due to inflammation. Aortic stenosis causes longstanding pattern changes from hypertrophy and pressure overload rather than transient vasospastic episodes with normal troponin.