Ascending aortic dissection presented as inferior myocardial infarction: a clinical and diagnostic mimicry

Abstract

Acute ST segment elevation myocardial infarction (STEMI) is typically associated with acute coronary thrombosis or plaque rupture. Rarely, STEMI can be associated with ascending aortic dissection, which represents the majority of acute aortic syndrome aetiologies and carries dreadful outcomes. Routine cardiac intervention with emergent cardiac catheterisation may lead to a higher mortality rate in this group of patients. We present a case of painless inferior STEMI in the setting of ascending aortic dissection. The patient had an inferior STEMI due to the involvement of the right coronary artery as an extension of the ascending aortic dissection. In this era of protocol-driven practice and the pressure to fulfil quality measures, we aim to alert emergency physicians, cardiologists and interventionalists of the possible presentation of painless ascending aortic dissection as an STEMI. The two pathologies characterise by crucial differences in their initial and ultimate management.

Suspected ST segment elevation myocardial infarction referred for primary angioplasty: a masquerader

“…Aortic dissection mimicking inferior ST-elevation myocardial infarction has been previously described, with misdiagnosis due to time pressures 8 9. Anterior ST-elevation myocardial infarction is rare but can occur due to compression of coronary ostia by haematoma, or occlusion by extension of the dissection flap 10…”

Current management of acute aortic syndrome

“…Myocardial ischaemia is among one of the three lethal cardiac complications of acute type A aortic dissection and intramural haematoma, and it is present in 10–15 per cent of cases . It creates difficulty in the initial diagnosis of aortic dissection, because the presence of ST‐segment abnormalities directs management towards acute coronary syndrome with antithrombotics and thrombolysis or percutaneous intervention, which renders the patient unfavourable for emergency aortic surgery due to significant bleeding tendency. A high index of suspicion with identification of eccentric aortic regurgitation by transthoracic echocardiogram and elevated D‐dimers can shift the management towards lethal aortic emergency .…”