Severe Chest Pain of Non-Cardiac Origin in a Patient with Coronary Artery Disease: A Case Report and Literature Review

Abstract

Chest pain is one of the most common reasons for emergency department presentation and remains a leading cause of hospital
admission worldwide. While acute coronary syndrome is the primary concern, particularly in older adults and patients with
established coronary artery disease, the majority of chest pain cases are ultimately attributable to non-cardiac etiologies.
Distinguishing cardiac from non-cardiac causes is clinically challenging, especially when initial investigations suggest
significant underlying coronary pathology.
We present the case of a 69-year-old male with extensive cardiovascular comorbidities, including prior coronary artery bypass
grafting, who presented with severe, persistent chest pain refractory to standard anti-ischemic therapy. Initial evaluation raised
concern for non–ST-elevation myocardial infarction based on symptoms, risk profile, and imaging findings. Despite appropriate
cardiac management, the patient’s symptoms persisted and his clinical course deteriorated, prompting further investigation.
Subsequent imaging revealed severe acute cholecystitis complicated by hepatic abscess formation, which was identified as
the true source of his chest pain.
This case underscores that non-cardiac conditions, particularly acute biliary pathology, can closely mimic acute coronary syndromes
and may present with chest pain unresponsive to conventional cardiac therapies, even in patients with known coronary artery disease.
Clinicians should maintain a broad differential diagnosis and reassess refractory chest pain systematically to avoid diagnostic
delay, reduce morbidity, and ensure timely, targeted management.