1 Aneurysmatic Patient Presenting with ST-Elevation Myocardial Infarction:

2 Role of Multimodality Imaging in Emergency Setting – a Case Report

3 Yusuf Ananda Fikri1*, Eka Prasetya Budi Mulia2, Faris Wahyu Nugroho2

1
4 General Practitioner, dr. R. Soetrasno Regional General Hospital, Rembang, Central Java,
5 Indonesia
2
6 Department of Cardiology and Vascular Medicine, dr. R. Soetrasno Regional General
7 Hospital, Rembang, Central Java, Indonesia
8

9 *Correspondence email : yusufananda@gmail.com

10 Corresponding address: Jl. Pahlawan No.16, Rembang, Central Java, Indonesia 59218
11
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2
3
4 ABSTRACT
5 Background: Aortic dissection with concurrent ST-elevation myocardial infarction (STEMI)
6 is rarely reported. As the proportion of myocardial infarction is higher in the emergency
7 setting compared to aortic dissection, the diagnosis of aortic dissection may be overlooked,
8 and it can be potentially fatal. By using bedside available information, detailed history taking
9 and multimodality imaging in the emergency setting, it is possible to avoid a mistaken
10 diagnosis. Here we present a case of aortic aneurysm presenting with anterior STEMI.
11
12 Case Presentation: A 79-year-old woman was admitted to our emergency department with
13 decreased consciousness. Shortly before the patient went unconscious, she had a short episode
14 of dyspnea. Her ECG showed marked ST elevation in the anterior leads. However, her chest
15 radiograph revealed mediastinal widening and a prominent aortic knob. Due to suspicion of
16 aortic dissection from the chest radiograph and loss of consciousness, which may be a sign of
17 malperfusion syndrome of aortic dissection, bedside handheld echocardiography was then
18 performed. It revealed hypokinesis of anterior and anteroseptal walls, pericardial effusion, and
19 dilated aortic root to ascending aorta with severe aortic regurgitation. The presence intimal
20 flap can not be clearly excluded. Based on her imaging and clinical findings, aortic dissection
21 was suspected and thrombolysis was postponed. The patient proceeded to undergo triple-rule-
22 out computed tomography, from which the finding of ascending aortic aneurysm was noted,
23 along with multiple stenosis of LAD (moderate-to-severe) and LCx (moderate), and there was
24 no presence of false lumen.
25
26 Conclusion: Acute aortic dissection should be considered as a differential diagnosis in
27 patients presenting with symptoms suggesting acute coronary syndrome. A suspected case of
28 acute aortic dissection should necessitate further imaging studies. Therefore, multimodality
29 imaging plays a vital role in the emergency setting, as it may avoid fatal consequences of
30 misdiagnosis and mistreatment.
31
32 Keywords: aortic aneurysm, aortic dissection, myocardial infarction, case report,
33 imaging
34 BACKGROUND
35 Acute aortic syndromes represent three life-threating conditions, including acute aortic
36 dissection, intramural hematoma, and penetrating aortic ulcer. Patients with acute aortic
37 syndrome may present with a broad spectrum of signs and symptoms, rendering them difficult
38 to diagnose in the emergency setting. 1 Aortic dissection presenting with ST-elevation
39 myocardial infarction (STEMI) is rarely reported. As the proportion of myocardial infarction
40 is higher in the emergency setting compared to aortic dissection, the diagnosis of aortic
41 dissection may be overlooked, and it can potentially lead to fatal outcomes. 2 By using bedside
42 available information, detailed history taking and multimodality imaging in the emergency
43 setting, it is possible to avoid a mistaken diagnosis. Here, we present a case of aortic
44 aneurysm presenting with anterior STEMI.
45
46 CASE PRESENTATION
47 A 79-year-old woman was admitted to the emergency department of a non-percutaneous
48 coronary intervention (PCI)--capable center hospital with decreased consciousness for 4
49 hours. She had a history of uncontrolled hypertension. Shortly before the patient went
50 unconscious, she had a short episode of dyspnea. The patient had long-standing hypertension
51 and had poor compliance with her medication. The patient’s family history is unremarkable.
52 Her vital signs at admission were as follows: blood pressure (BP) 200/105 mmHg; heart rate
53 (HR) 117 bpm; respiratory rate (RR) 40 x/min; and oxygen saturation of 52%. Physical
54 examination revealed diffuse rales in both lungs. Blood gas analysis presented metabolic
55 acidosis with type 1 respiratory failure. Her ECG showed marked ST-segment elevation in the
56 anterior leads (Figure 1). However, her chest radiograph revealed mediastinal widening and a
57 prominent aortic knob (Figure 2).

58
59 Figure 1. ECG showed marked ST elevation in the anterior leads.
60
61 Figure 2. Chest radiograph revealed mediastinal widening and a prominent aortic knob.

62 Due to suspicion of aortic dissection from the chest radiograph and loss of
63 consciousness, which may be a sign of malperfusion syndrome of aortic dissection, bedside
64 handheld echocardiography was performed approximately 4 hours after admission. It revealed
65 hypokinesis of anterior and anteroseptal walls, pericardial effusion, and dilated aortic root to
66 ascending aorta with severe aortic regurgitation. The presence of intimal flap can not be
67 clearly excluded (Figure 3, supplementary movie S1). Based on her imaging and clinical
68 findings, aortic dissection was suspected, and reperfusion therapy was postponed.
69
70 Figure 3. Bedside echocardiography revealed the suspected intimal flap (red arrow) and pericardial
71 effusion (red asterisk)

72 The patient subsequently proceeded to undergo triple-rule-out computed tomography

73 at approximately 6 hours after admission, from which the finding of ascending aortic
74 aneurysm with diameter of 4.81 cm at its largest segment was noted, and there was no
75 presence of false lumen (supplementary movie S2). Coronary CT also depicted multiple
76 stenosis of left anterior descending artery (LAD), with the most significant stenosis (54%)
77 found at the proximal part. Hard and soft plaques were also seen at the first diagonal branch
78 (D1), along with 70% stenosis at its proximal part. The narrowing of left circumflex artery
79 (LCx) was also observed, with the most significant degree of stenosis at its medial part (56%).
80 The patient’s right coronary artery along with its branches, were within normal limits.
81 The patient's was diagnosed with anterior STEMI Killip 3 with acute lung edema,
82 respiratory failure with hypoxic encephalopathy, hypertensive emergency, and ascending
83 aortic aneurysm. The patient’s family refused to be referred to a PCI-capable center, mainly
84 due to the distance between our hospital to the center, which is about 100 km (3-hour ride).
85 The patient’s advanced age also became one of the factors which made the patient reluctant to
86 be transferred. Right after no presence of aortic dissection was confirmed on triple-rule-out
87 CT, he patient was medically (conservatively) managed in our hospital with aspilet 1x80 mg,
88 clopidogrel 1x75 mg, intravenous (IV) furosemide 2x20 mg, fondaparinux 1x2.5 mg,
89 lansoprazole 1x30 mg, isosorbide dinitrate 3x5 mg, atorvastatin 1x40 mg, valsartan 2x80 mg,
90 and concor 1x5 mg. Her consciousness gradually improved and her other clinical conditions
91 remained uneventful during daily follow-ups. The patient was discharged home at Day-7 of
92 hospitalization. Regarding the anterior STEMI, the follow-up plan is 3-month re-evaluation of
 93 echocardiography, treadmill test, and rehabilitation prescription. Follow-up CT scan of the
94 aneurysm will be performed after 6 months according to the largest diameter of the aneurysm.
95
96 DISCUSSION
97 There are currently limited studies reporting the prevalence of concomitant acute myocardial
98 infarction with acute aortic syndrome. According to Liu et al, approximately 0.1% patients
99 with acute myocardial infarction (MI) and 7.5% patients with aortic dissection had a
100 concomitant diagnosis of acute MI and aortic dissection. 3 Incorrectly diagnosing aortic
101 dissection as myocardial infarction can result in insufficient utilization of thrombolytic,
102 antiplatelet, and anticoagulant medications, leading to potential negative outcomes. 4
103 Inaccurate administration of thrombolytic agents in patients with aortic dissection
104 misdiagnosed with STEMI has also been associated with mortality. 5 In this case, we decide to
105 postpone reperfusion therapy as we noted radiological findings suggestive of acute aortic
106 syndrome.
107 Known as a great masquerader, patients with aortic dissection may present with
108 various non-specific symptoms, leading to misdiagnosis in approximately 25% of cases. 6,7
109 Although its most typical symptoms include chest pain that is sharp in quality and abrupt in
110 onset, other symptoms associated with the obstruction of aortic branches, such as stroke,
111 paraplegia, visceral ischemia, and limb ischemia, may also occur. 8 In our case, the patient
112 presented with loss of consciousness, which may be suggestive of ‘malperfusion syndrome’
113 caused by obstruction of aortic branches. The episode of dyspnea, which the patient
114 experienced before she went unconscious, may also be a symptom of aortic regurgitation due
115 to dissecting aortic aneurysm. Aortic dissection can also result in pericardial effusion due to
116 transudation through the false lumen's wall or, less frequently, direct dissection rupture into
117 the pericardial cavity. 9
118 Unlike those of aortic dissection, typical characteristics of ischemic chest pain in acute
119 MI include sudden and prolonged substernal chest pain, and might be accompanied by
120 autonomic symptoms such as nausea and sweating. 10 However, in our case, it was difficult to
121 characterize the quality of chest pain that the patient encountered since the patient was
122 brought unconscious to our emergency department.
123 Multimodality imaging plays a pivotal role in patients with aortic aneurysms
124 presenting with ST-elevation myocardial infarction (STEMI) by providing a comprehensive
125 assessment of both the cardiovascular structures involved. Aortic aneurysms and STEMI are
126 distinct yet potentially interconnected conditions that require accurate diagnosis and prompt
127 intervention. While electrocardiography (ECG) and cardiac biomarkers are crucial for
128 diagnosing STEMI, they do not provide information about the underlying anatomical
129 anomalies, such as aortic aneurysms. In such cases, advanced imaging techniques such as
130 computed tomography angiography (CTA) and echocardiography can provide detailed
131 insights into the location, extent, and characteristics of the aortic aneurysm. This information
132 is essential for guiding treatment decisions, including determining the need for immediate
133 aortic intervention alongside coronary revascularization. 11,12 Furthermore, Kirigaya et al. also
134 demonstrated that echocardiographic measurement of proximal aortic diameter is one of the
135 most useful parameters in differentiating STEMI from type A acute aortic dissection. 13
136 In patients with coexisting aortic aneurysm and STEMI, multimodality imaging also
137 assists in precise surgical planning and procedural guidance. Aortic aneurysms require careful
138 evaluation to determine the appropriate management strategy, which might involve surgical
139 repair or endovascular intervention. Simultaneously, the management of STEMI demands
140 rapid coronary revascularization to salvage myocardium and prevent adverse outcomes.
141 Multimodal imaging techniques such as magnetic resonance imaging (MRI) and three-
142 dimensional echocardiography provide detailed anatomical information necessary for
143 selecting the optimal approach for aortic intervention, while also assessing the viability of the
144 myocardium. Integrating these imaging modalities enables a comprehensive assessment that
145 aids in determining the sequence and timing of interventions to address both the aortic
146 pathology and the coronary artery obstruction effectively. 14,15 Bedside transthoracic
147 echocardiography aids in distinguishing acute aortic dissection from STEMI by visualizing an
148 intimal flap or intramural hematoma. In some cases, findings of aortic regurgitation with
149 normal valve cusps, aortic root dilation and pericardial effusion should also raise the
150 possibility of aortic dissection. 16
151 Multimodality imaging provides crucial information for risk stratification and long-
152 term monitoring of patients with concurrent aortic aneurysm and STEMI. The presence of an
153 aortic aneurysm can impact the prognosis and management of STEMI. Comprehensive
154 imaging allows clinicians to assess the size, location, and characteristics of the aortic
155 aneurysm, which in turn contributes to risk stratification and determining the potential need
156 for elective aortic repair after the acute phase of STEMI management. 17 Additionally, post-
157 intervention surveillance involves serial imaging to monitor aortic morphology and detect
158 potential complications such as endoleaks. Multimodal imaging, including follow-up CTA
159 and echocardiography, aids in detecting changes in both the aortic and coronary structures,
160 facilitating timely intervention if needed. 18
161
162 CONCLUSION
163 Acute aortic dissection should be considered as a differential diagnosis in patients presenting
164 with symptoms suggesting acute coronary syndrome. It is also important to exclude acute
165 aortic dissection prior to reperfusion therapy in patients with acute MI. A suspected case of
166 acute aortic dissection should necessitate further imaging studies. Multimodality imaging
167 plays a vital role in the emergency setting, as it may avoid fatal consequences of misdiagnosis
168 and mistreatment.
169
170 LIST OF ABBREVIATIONS
171 BP = blood pressure
172 CT = computed tomography
173 CTA = computed tomography angiography
174 ECG = electrocardiography
175 HR = heart rate
176 LAD = left arterial descending
177 MI = myocardial infarction
178 MRI = magnetic resonance imaging
179 PCI = percutaneous coronary intervention
180 RR = respiratory rate
181 STEMI = ST-elevation myocardial infarction
182
183 DECLARATIONS
184
185 Funding
186 The authors state no funding involved.
187
188 Conflicts of interest
189 The authors declare that they have no conflicts of interest.
190
191 Ethics approval
192 Not applicable.
193
194 Consent to participate
195 Not applicable.
196
197 Written Consent for publication
198 Written, informed consent has been obtained from the patient included in this article.
199
200 Availability of data and materials
201 Not applicable.
202
203 Code Availability
204 Not applicable.
205
206 Authors’ contribution
207 YAF contributed to the drafting of the work, data collection, and was a major contributor in
208 writing the manuscript.
209 EPBM and FWN contributed to the conception of the case report and review of the final draft.
210 All authors read and approved the final manuscript.
211
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