Giant Hiatal Hernia Mimicking Acute Coronary Syndrome: A Case Report.

Hiatal hernia is a condition that involves the herniation of abdominal contents, most commonly the stomach, through the esophageal hiatus into the thoracic cavity. While often asymptomatic, large hiatal hernias can cause compression of mediastinal structures, producing symptoms that mimic acute coronary syndrome (ACS) such as chest pain, dyspnea, and elevated cardiac biomarkers. A 68-year-old woman with hypertension presented with five days of right-sided chest pain radiating to the back with nausea. Laboratory evaluation revealed elevated high-sensitivity troponin I (267.2 ng/L), pro-B-type natriuretic peptide (713 pg/mL), and D-dimer (1606 ng/mL fibrinogen-equivalent units (FEU)). Initial electrocardiogram showed non-specific findings. Chest X-ray demonstrated a retrocardiac opacity with gas-filled bowel loops and mediastinal shift, suspicious for a large hiatal hernia. Pulmonary embolism was ruled out via computed tomography (CT) pulmonary angiography. CT scan of the chest and abdomen confirmed a large hiatal hernia containing most of the stomach and part of the left colon. The patient was managed conservatively with intravenous fluids, serial cardiac biomarker monitoring, and thromboembolic prophylaxis. Her symptoms and biomarkers gradually improved, and surgical intervention was deferred due to age and comorbidities. This case highlights the diagnostic challenge posed by giant hiatal hernias mimicking ACS. Early recognition through imaging can prevent unnecessary invasive procedures, reduce healthcare costs, and guide appropriate management.