Acute Aortic Dissection Mimicking Inferior Myocardial Infarction: A Call For Greater Awareness

Background: Acute Aortic Dissection (AAD) is a great masquerader with high mortality rate. At initial
presentation, the estimated mortality rate of untreated aortic dissection is 40% with increasing rate
of 1% hourly. Ascending aortic dissection may result in coronary malperfusion, which can cause ST-
elevation myocardial infarction. The presentations of the two conditions overlap to some degree and
are easily confused. Therefore, it is crucial to diagnose STEMI that occurs secondary to AAD based on
meticulous history, scoring, and algorithm since the therapies used to treat MI, can be lethal for
patients with AAD.

Case Illustrations: A 52-year-old male ex-smoker with history of uncontrolled hypertension was
reffered from suburban hospital with inferior STEMI. The patient presented a sudden onset of sharp
retrosternal pain, radiating to the back, associated with nausea and syncope. The vital signs showed
a blood pressure of 123/86 mmHg and a heart rate of 60 bpm. ECG showed inferior ST-segment
elevation. Laboratory resulted in slight elevation CKMB of 30 U/L, others were unremarkable.
Aspirin, clopidogrel and maximal dose of atropine sulfate were administered in the former hospital.
The x ray showed double aortic contour. Aortic Dissection Detection Risk Score (ADD-RS) showed 2
points which needs further conclusive imaging. Based on algorithm, the transthoracic
echocardiogram (TTE) and CT angiography was carried out. An urgent transthoracic echocardiogram
revealed hypokinesia of inferoseptal wall, moderate aortic regurgitation, intimal tear in ascending
aorta. CT angiography fully confirmed a Stanford type A (Debakey type II) AAD arising from the level
of aortic root to aortic arch. Patient was planned to be reffered for Bentall procedure but he refused.
The patient went into cardiac arrest 3 days after hospital discharge.

Conclusions

Acute aortic dissection resembling inferior myocardial infarction is a challenging diagnosis. All
clinicians should have a greater awareness and careful clinical evaluation of the underlying cause.
Algorithm and scoring can be used in order to generate insights which might help to optimise triage
of patients with STEMI-like clinical presentation.

Keywords: Acute Aortic Dissection, Inferior ST-elevated Myocardial Infarct, Diagnosis

 • Acute Aortic Dissection (AAD) is a great masquerader with high mortality rate of 40%,
increasing 1% hourly

• Ascending aortic dissection may result in coronary malperfusion, which can cause STEMI
presentation

• STEMI secondary to AAD is a crucial diagnosis since the therapies used to treat MI, can be
lethal for patients with AAD.

• A 52-year-old male with retrosternal pain, radiating to the back for 3 hr with nausea,
syncope, breathlessness

• History of uncontrolled hypertension and tobacco use

• Aspirin, clopidogrel and maximal dose of atropine sulfate were administered from referring
hospital.

In our emergency department

The patient still suffered from heavy chest pain, Visual analaog scale of 8, radiating to the back

Physical finding showed

BP 123/86 mmHg

HR 60 bpm

RR 23 x/min

SpO2 98% o2 3 lpm

Grade 4 diastolic murmur at aortic area radiating to left lower sternal border

and

Not only was the extremity cold in palpation but also a clammy skin was found

ADD RS is found to be 2

The ECG showed

Sinus Rhytm 60x/m, STEMI Inferior dan LV Hypertrophy

Chest X-ray showed a widened mediastinum, Wide aortic contour, a calcium sign and cardiomegaly

ADD-RS scoring, ecg and xray made a aortic imaging and surgical consultation needed

So patient underwent echocardiography that showed

Inferoseptal wall hypokinesia, moderate AR, intimal tear in ascending aorta

And CT scan of thoracoabdominal with contrast showing Stanford type A (Debakey type II) AAD
arising from the level of aortic root to aortic arch with ascenden aortic dilatation (5,1 cm)

Laboratory findings show slight elevation of CKMB,

Monitoring

Vital sign

Fluid balance volume status and hemodynamics optimization

Multidisciplinary approaches were taken including cardiothoracic surgery consultation

Adequate oxygen supplementation

Anticoagulant and antiplatelet  STOP

Antihypertensive therapy along with beta blocker and morphine were administrated

Patient was also informed to a referral plan for Bentall procedure with hemiarch replacement but he
refused

Discussion

Myocardial infarction caused by extension of an acute Stanford type A aortic dissection is a rare but
deadly event, occurring in approximately 3% patients with aortic dissection.

Differentiating acute Stanford A aortic dissection with coronary malperfusion from true acute
myocardial infarction is challenging for emergency physicians, especially under pressure to achieve
short reperfusion times. Important clinical clues for differential diagnosis may be overlooked.

In the absence of a rapid, accurate, and readily available diagnostic test, the current diagnosis of
aortic dissection requires comprehensive interpretation of available information. Here we have a
simple risk assessment tool focusing on specific high-risk predisposing conditions, pain features, and
physical examination findings called aortic dissection detection risk score. The results from this study
suggested that the aortic dissection detection risk score, with the use of only information that is
available at bedside, offers adequate sensitivity to capture the vast majority of patients presenting
with acute aortic dissection. This aortic dissection detection risk score is highly sensitive (95.7%) for
the detection of acute aortic dissection when applied to the patients diagnosed with aortic
dissection in the IRAD The International Registry of Acute Aortic Dissection Substudy (IRAD)

All this clues lead to a conclusion that our patient had underlying mechanisms of STEMI that is aortic
regurgitation confirmed by ct scan as expedited aortic imaging.

Medical management was given to maintain the patient bp and hr, since the patient tend to be
hypertensive and tachycardiac. Surgery plan that should be cito was made and risk for further
complication including death was explained but our patient still refused.

Conclusion

1. Acute aortic dissection resembling inferior myocardial infarction is a challenging diagnosis.

2. All clinicians should have a greater awareness and careful clinical evaluation of the
underlying cause. Is it conventional stemi? or stemi with accompanying catastrophe.
3. Algorithm and scoring can be used in order to generate insights which might help to
optimize triage of patients with STEMI-like clinical presentation. Especially in rural areas or
limited facility center.

Gaperlu kynny  In our patient, there were several indicators of aortic dissection. First,
detailed characterization of chest pain in the emergency department may have provided
clues to aortic dissection. Typically, aortic dissection presents with severe tearing chest pain
that instantly reaches its maximal intensity. The qualitative nature of the patient’s chest pain
was not clarified. Second, the patient had a history of uncontrolled hypertension. Third chest
radiography had revealed mediastinal widening an abnormal aortic contour, which should
have prompted further imaging studies. Third, a murmur from aortic regurgitation had been
detected on physical examination.