Myocardial Infarction as a Complicating Factor in Aortic Dissection Diagnosis and Treatment

Abstract

INTRODUCTION: Nearly 30% of aortic dissection (AoD) cases are misdiagnosed. Suspicion is highest in patients presenting with both chest and back pain but back pain is only seen in 53%. Most present with hypertension and are male. Predictors of inhospital death for patients with type A AoD include female sex, abrupt onset of pain, new Q waves and/or ST segment deviation, and hypotension. CASE PRESENTATION: A 66-year-old woman with a history of hypertension presented with sudden anterior chest pain. Electrocardiogram (EKG) was diagnostic for anterior ST elevation myocardial infarction (STEMI). The patient was hypotensive and intermittently in heart block. She was loaded with aspirin, clopidogrel, and atorvastatin, started on a dopamine drip, and taken for cardiac catheterization. An intraaortic balloon pump (IABP) was inserted but aortography revealed the presence of an acute dissection. IABP was immediately discontinued. The patient underwent ascending aorta and aortic valve repair. Despite surgery, cardiogenic shock persisted, multi-organ failure ensued, and the patient died. DISCUSSION: Due to this patient's presentation as an anterior STEMI, she was treated with the acute coronary syndrome algorithm. It is unlikely that avoidance of antiplatelets, dopamine, and/or IABP would have altered her course given her high risk features. Nevertheless, AoD must be considered in the differential of STEMI. An aortogram should be performed prior to IABP use in cases with high clinical suspicion. CONCLUSIONS: This patient presented as an unusual case of anterior STEMI secondary to left main disease from an aortic dissection. This case highlights the STEMI differential diagnosis and application of aortography prior to IABP use.

Aortic dissection presenting as inferior ST elevation myocardial infarction and Importance of early echocardiography

“…Myocardial infarction due to aortic dissection is uncommon. Stanford type A Aortic dissection (TAAD) can cause myocardial hypo perfusion in 8-10% patients due to retrograde dissection causing pressure effect in coronary ostium (1). TAAD is usually involved with right coronary artery (RCA) and causes inferior STEMI in 3% of patients (1).…”

“…Stanford type A Aortic dissection (TAAD) can cause myocardial hypo perfusion in 8-10% patients due to retrograde dissection causing pressure effect in coronary ostium (1). TAAD is usually involved with right coronary artery (RCA) and causes inferior STEMI in 3% of patients (1). Of the patients presenting with both condition, only 1.5% patients will receive primary PCI (2).…”