When chest pain is not what it seems: time for right diagnosis and right treatment—a case report

Background Chest pain is a common reason for emergency department (ED) visits, yet not all cases are attributable to coronary artery disease (CAD). The 2024 European Society of Cardiology (ESC) guidelines emphasize the importance of invasive coronary function testing in patients with angina and non-obstructive coronary arteries. Understanding alternative causes of chest pain is crucial for appropriate diagnosis and management. Case summary A 58-year-old woman with hypertension, prediabetes, and a history of Takotsubo Syndrome presented with recurrent chest pain episodes, prompting multiple ED visits. Initial cardiac evaluations, including electrocardiogram (ECG), troponin levels, and ECG stress testing, were unremarkable. Repeated invasive coronary angiography (ICA) with a full physiological assessment ruled out obstructive CAD, microvascular dysfunction, and coronary vasospasm, suggesting a ‘sensitive heart syndrome’. Further evaluation revealed a spinal schwannoma at the thoracic level, compressing the anterior spinal roots. Neuropathic chest pain was confirmed, and treatment with pregabalin led to symptom relief. Discussion This case highlights the importance of a structured stepwise diagnostic approach to chest pain. When cardiac causes are excluded, alternative diagnoses such as neuropathic pain should be considered.