A 60-year-old male with past medical history of hypertension, presented to emergency department complaining of chest pain for 2 hours, the pain was described as tearing, substernal pain and was radiating to the neck and shoulders and associated with nausea and sweating. Initial vital signs showed Blood pressure of 120/90 mmHg in right arm, and 110/70 mmHg in left arm, Heart rate of 90 beat per minute, Respiratory rate was 18 breath per minute, temperature of 37.6 ℃ and Oxygen saturation of 95% breathing ambient air. Physical exam was significant for jugular venous distension and cardiac exam showed normal heart sounds, an early diastolic murmur, 3/6 in intensity, best heard on left 3 rd intercostal space without radiation, and no S3 or S4 gallop. Initial lab results showed a white blood cell count of 8.1 k/μL, hemoglobin of 12.2 g/dL, platelets of 177 k/μL, creatinine of 1.19 mg/dL, AST of 30 IU/L, ALT of 29 IU/L, initial set of troponin I was 0.02 ng/mL. Twelve lead electrocardiogram (EKG) showed ST segment elevations in inferior leads ( Figure 1). Emergent coronary angiography was done and revealed normal coronary arteries without evidence of dissection ( Figure 2). After the catheter was pulled back across the aortic valve, an aortic root angiogram was performed and showed aortic insufficiency (grade 3), and an aortic dissection flap that started in the ascending aorta and progressed through to the descending aorta ( Figure 3); this was classified as a Stanford type A (DeBakey type I). A bedside transthoracic echocardiogram was also performed after cardiac catheterization, and showed an EF of 40 % with inferior wall hypokinesia, a dilated aortic root with an evidence of intimal tear in the ascending aorta and moderate aortic regurgitation. In addition, mild pericardial effusion was also noted.Vascular surgery team was immediately consulted, and an aortic computed tomography (CT) scan was done and revealed a Stanford type A (DeBakey type I) aortic Abstract: Acute aortic dissection (AD) is the most common life-threatening disorder affecting the aorta with an incidence that ranges between 5 to 30 cases per million people per year. The symptoms of aortic dissection may be variable and can mimic other more common conditions such as myocardial ischemia. We report a case of a 60-year-old male who presented with inferior wall ST-elevation myocardial infarction (MI).Emergent coronary angiography revealed an ascending aortic dissection with normal coronary arteries. In addition, his aortic dissection was complicated with pericardial tamponade. The patient was managed with an immediate surgical repair, after that he had an uncomplicated postoperative course and was discharged in a stable condition. This case report illustrates the importance of having a high index of suspicion for AD in cases of chest pain. If AD is suspected in a patient with acute coronary syndrome (ACS), confirming the diagnosis with the appropriate imaging studies should be done as quickly as possible, as misdiagnosis with ACS may lead to the inappr...
