A Mirror-Image Heartache: Reflections on a False Diagnosis of Acute Coronary Syndrome in a Patient With Situs Inversus Totalis

TL;DR

A patient with a rare heart condition was mistakenly diagnosed with a heart attack due to mirrored organ placement, highlighting the need for careful clinical judgment.

Contribution

This case emphasizes the importance of recognizing anatomical variants like situs inversus totalis to avoid misdiagnosis in acute chest pain evaluation.

Findings

A 30-year-old man with situs inversus totalis was initially misdiagnosed with acute coronary syndrome due to mirrored ECG findings.

Correct diagnosis was achieved through clinical correlation, imaging, and mirrored ECG lead placement, confirming no myocardial infarction.

The case underscores the need for integrating bedside assessment with multimodal investigations in patients with rare anatomical variants.

Abstract

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of the thoracic and abdominal organs. Unrecognized SIT can create diagnostic confusion in patients presenting with chest pain, as standard electrocardiographic (ECG) lead placement may generate waveforms that mimic acute coronary syndromes (ACS). We report the case of a 30-year-old physically fit man who presented with acute central chest pain following exertion. Initial investigations revealed nonspecific ECG abnormalities and a mildly elevated high-sensitivity troponin level, leading to a presumptive working diagnosis of ACS. On structured re-examination, a right-sided apex beat was identified, and chest radiography confirmed dextrocardia. A repeat ECG performed with mirror-image precordial lead placement restored normal waveforms, and serial cardiac biomarkers showed no dynamic trend, confirming the absence of myocardial infarction. This case illustrates that even in modern, protocol-driven medicine, diagnostic precision in acute chest-pain evaluation depends on clinical judgment derived from correlating systematic bedside assessment with multimodal investigation, including imaging, ECG, and biomarker analysis. This integrative approach enhances diagnostic accuracy, prevents unnecessary interventions, and promotes safe, patient-centered outcomes, particularly in individuals with rare anatomic variants such as SIT.

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