A patient presents with chest pain and shortness of breath; labs show normal troponin and D-dimer. What is the most likely diagnosis?

• A. Panic attack
• B. Myocardial infarction
• C. Pulmonary embolism
• D. Aortic dissection

Answer: (A)

When evaluating chest pain with shortness of breath, doctors use biomarkers to separate potential life-threatening cardiac or thromboembolic causes from noncardiac ones. Troponin rises with myocardial injury, so a normal troponin level makes acute myocardial infarction unlikely. D-dimer is elevated with thromboembolic processes like pulmonary embolism, so a normal D-dimer reduces the likelihood of a PE in someone with chest pain and dyspnea.

Given both biomarkers are normal, there’s no biochemical evidence pointing to heart muscle damage or a clot in the lungs. A panic attack fits this pattern well: it can produce chest discomfort, chest tightness, shortness of breath, and rapid heart rate due to heightened sympathetic activity, yet cardiopulmonary workup is unrevealing. The absence of troponin elevation and a normal D-dimer align with a noncardiac, nonthromboembolic cause such as an anxiety-driven panic attack.

In practice, this remains a diagnosis of exclusion and doesn’t rule out other possibilities entirely, but the presentation strongly supports a panic attack as the most likely explanation. If needed, addressing acute anxiety with calming breathing techniques and reassurance, followed by longer-term anxiety management, is appropriate, while continuing to monitor for any new or changing symptoms.