Clinical Cases
Real-world cardiology cases — presentation, workup, diagnosis, and management — for doctors and students who learn best by working through the patient in front of them.
Textbooks teach the disease; cases teach the patient. Each case on this page is built the way real clinical reasoning happens — starting with a presentation, working through the differential, and ending with the decision-making and teaching points that matter at the bedside or in the cath lab.
Browse by Category
Coronary Artery Disease
Acute coronary syndromes, stable angina, and revascularization decisions.
Structural Heart Disease
Valvular disease, congenital defects, and structural interventions.
Arrhythmias
ECG-based diagnosis and management of rhythm disorders.
Heart Failure & Devices
Heart failure management and device-based therapy (pacemakers, ICDs, CRT).
Featured Cases
How Our Cases Are Structured
- Patient Presentation — chief complaint, history, and exam findings
- Workup — relevant investigations, ECG, imaging, and labs
- Diagnosis & Differential — reasoning through the possibilities
- Management — the clinical decision and rationale
- Key Teaching Points — the takeaways to remember
Learn From Every Patient
New cases are added regularly. Have a teaching case to suggest or contribute?
Clinical Case Vault: Chest Pain
12 graded chest pain cases — Beginner, Intermediate, and Expert level — for structured clinical reasoning practice. Click each case to reveal the full workup, diagnosis, and teaching point.
Beginner Level
Presentation: 58-year-old male, smoker and hypertensive, sudden severe crushing central chest pain radiating to the left arm and jaw, onset while climbing stairs, with sweating and nausea, not relieved by rest, duration 45 minutes.
History & Exam: Diaphoretic, HR 96/min, BP 150/92 mmHg, S4 gallop, no murmurs.
Investigations: ECG: ST-elevation in V1-V4 with reciprocal ST depression in II, III, aVF. Troponin markedly elevated.
Diagnosis: Acute ST-elevation myocardial infarction (anterior wall, LAD territory).
Teaching Point: Classic ischemic chest pain with anterior STEMI ECG pattern. Recognize the LAD territory and prioritize door-to-balloon time.
Presentation: 62-year-old diabetic woman with recurrent retrosternal chest tightness on climbing two flights of stairs, relieved within 5 minutes of rest, no radiation or diaphoresis.
History & Exam: Physical exam unremarkable, normal heart sounds.
Investigations: Resting ECG normal. Exercise stress test shows 2 mm ST depression at high workload, reproducing symptoms.
Diagnosis: Stable (exertional) angina pectoris due to significant coronary artery disease.
Teaching Point: A predictable exertional pattern relieved by rest is the hallmark of stable angina. Stress testing confirms ischemic burden.
Presentation: 34-year-old male with burning retrosternal discomfort after large spicy meals, worse lying down, partially relieved by antacids, no exertional relation.
History & Exam: Normal cardiac exam, mild epigastric tenderness.
Investigations: ECG normal, troponin negative.
Diagnosis: Gastroesophageal reflux disease (GERD) — non-cardiac chest pain.
Teaching Point: Postprandial, positional, burning-quality pain suggests a non-cardiac cause, but ACS must always be excluded first regardless of how typical GERD symptoms appear.
Presentation: 24-year-old male with recent viral upper respiratory infection presents with sharp pleuritic chest pain worse lying supine, improved leaning forward, with low-grade fever.
History & Exam: Pericardial friction rub on auscultation.
Investigations: ECG shows diffuse concave ST elevation with PR segment depression; troponin mildly elevated.
Diagnosis: Acute pericarditis (likely viral), with mild myocardial involvement.
Teaching Point: Positional pleuritic pain, a friction rub, and diffuse (not localized) ST elevation with PR depression distinguish pericarditis from STEMI.
Intermediate Level
Presentation: 70-year-old diabetic woman with two days of vague epigastric discomfort, fatigue, and mild dyspnea, with minimal chest pain.
History & Exam: Mild diaphoresis, otherwise unremarkable exam.
Investigations: ECG shows subtle T-wave inversions in anterolateral leads; troponin elevated.
Diagnosis: NSTEMI with atypical/silent presentation due to diabetic autonomic neuropathy.
Teaching Point: Maintain a high index of suspicion for ACS in diabetics, the elderly, and women presenting with atypical or minimal chest pain. Troponin elevation confirms myocardial injury even with a subtle ECG.
Presentation: 55-year-old hypertensive male with sudden tearing chest pain radiating between the shoulder blades, followed by a brief syncopal episode.
History & Exam: Blood pressure differential of 20 mmHg between arms; early diastolic murmur of aortic regurgitation.
Investigations: ECG nonspecific; chest X-ray shows a widened mediastinum.
Diagnosis: Acute aortic dissection (Type A).
Teaching Point: Tearing pain, inter-arm BP differential, and a widened mediastinum are red flags. Confirm with CT angiography before considering anticoagulation or thrombolysis, which would be catastrophic if the diagnosis is dissection rather than ACS.
Presentation: 45-year-old woman on oral contraceptives, recent long-haul flight, sudden pleuritic chest pain, dyspnea, and mild hemoptysis.
History & Exam: Tachycardic, tachypneic, low-grade fever, unilateral calf swelling.
Investigations: ECG shows sinus tachycardia with an S1Q3T3 pattern; D-dimer elevated; CT pulmonary angiogram confirms pulmonary embolism.
Diagnosis: Acute pulmonary embolism.
Teaching Point: Recognize Virchow’s triad risk factors, use a validated pre-test probability score (e.g., Wells), and note the classic but insensitive S1Q3T3 pattern. Pleuritic quality and hypoxia help distinguish PE from ischemic cardiac pain.
Presentation: 38-year-old male smoker with recurrent chest pain at rest, often in the early morning, each episode resolving spontaneously within 15-20 minutes.
History & Exam: Normal examination between episodes.
Investigations: ECG during an episode shows transient ST elevation that resolves with symptom resolution; angiography shows no significant fixed stenosis but a positive provocation test.
Diagnosis: Vasospastic (Prinzmetal) angina.
Teaching Point: Rest-pattern angina with transient ST elevation and angiographically normal coronaries points to coronary vasospasm. Treat with calcium channel blockers and nitrates; avoid nonselective beta-blockers, which can worsen spasm.
Expert Level
Presentation: 33-year-old woman, 6 weeks postpartum, no traditional cardiovascular risk factors, sudden severe chest pain.
History & Exam: No prior cardiac history; otherwise well.
Investigations: ECG shows ST elevation in lateral leads; troponin elevated. Angiography reveals no atherosclerotic plaque but a dissection flap in the mid-LAD.
Diagnosis: Spontaneous coronary artery dissection (SCAD).
Teaching Point: Consider SCAD in young women, especially peripartum, and those with fibromuscular dysplasia. Angiographic appearance differs from atherosclerosis; conservative management is often preferred over PCI when flow is preserved.
Presentation: 68-year-old woman develops severe chest pain and dyspnea shortly after sudden emotional bereavement, mimicking an anterior STEMI.
History & Exam: Acute distress, otherwise unremarkable cardiovascular exam.
Investigations: ECG shows diffuse ST elevation, deep T-wave inversions, and prolonged QT; troponin only mildly elevated relative to the degree of ECG change. Angiography shows no obstructive CAD; echocardiogram reveals apical ballooning with basal hyperkinesis.
Diagnosis: Takotsubo (stress-induced) cardiomyopathy.
Teaching Point: Consider Takotsubo in postmenopausal women following acute emotional or physical stress. The disproportion between ECG/wall-motion changes and modest troponin rise, plus the apical ballooning pattern, are key clues. LV dysfunction is usually reversible.
Presentation: 26-year-old competitive athlete with recurrent exertional chest pain and occasional near-syncope during intense exercise.
History & Exam: Normal resting cardiac exam.
Investigations: Resting ECG normal; exercise ECG shows transient ST depression at peak exertion. Coronary angiography reveals systolic compression (“milking effect”) of the mid-LAD with no fixed atherosclerotic lesion.
Diagnosis: Symptomatic myocardial bridging.
Teaching Point: Dynamic systolic compression on angiography, distinct from fixed stenosis, defines myocardial bridging. Beta-blockers are first-line therapy; nitrates can worsen symptoms by increasing compression and should be avoided.
Presentation: 45-year-old male develops chest pain and hypotension within minutes of an insect sting, with associated urticaria and wheezing.
History & Exam: Signs of an acute allergic reaction alongside cardiac symptoms.
Investigations: ECG shows ST elevation in inferior leads during the reaction; troponin elevated. Coronary angiography shows no significant obstructive disease.
Diagnosis: Kounis syndrome (allergic acute coronary syndrome, Type I variant).
Teaching Point: Recognize concurrent allergic/anaphylactic features with an ACS-like presentation. Management must balance anti-allergic treatment with cardiac care; use epinephrine cautiously given its cardiac effects.