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Diagnosis and management of patients with acute cardiac symptoms, troponin elevation and culprit-free angiograms
  1. Sean Gallagher1,2,3,
  2. Dan A Jones1,2,3,
  3. Vijay Anand1,
  4. Saidi Mohiddin1,2,3
  1. 1Department of Cardiology, Barts and the London NHS Trust, London, UK
  2. 2William Harvey Research Institute, Queen Mary and Westfield University, London
  3. 3NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London, UK
  1. Correspondence to Dr Saidi Mohiddin, Department of Cardiology, London Chest Hospital, Bonner Road, London E2 9JX, UK; saidi.mohiddin{at}


Patients with acute cardiac symptoms, elevated cardiac troponin and culprit-free angiograms comprise a significant proportion of patients admitted with presumed acute coronary syndromes (ACS). International guidelines recommend that these patients receive lifelong secondary prevention under the presumption that angiographically undetectable coronary artery disease is the likeliest cause for their presentation. Recent studies using cardiac MRI suggest myocarditis to be the most common cause of these presentations. Emerging data also suggest that myocarditis presenting like an ACS may not be benign. In this article the current literature on patients presenting with acute cardiac symptoms, elevated cardiac troponins but culprit-free angiograms is reviewed, focusing on the diagnostic utility of cardiac MRI in this cohort, and the importance of diagnosing acute myocarditis. The development of higher sensitivity troponin assays will undoubtedly lead to an increase in the number of patients with presumed ACS but culprit free angiography. Robust management pathways including cardiac MRI are vital for cardiac centres dealing with these patients in order to achieve cost-effective, individualised patient care.

  • Acute coronary syndromes
  • normal coronary arteries
  • myocarditis
  • primary PCI
  • preconditioning
  • stable angina
  • sudden cardiac death
  • cardiomyopathy apical
  • diastolic dysfunction
  • cardiomyopathy hypertrophic

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.