Aneurysmatic Patient Presenting with ST-Elevation Myocardial Infarction: Role of Multimodality Imaging in Emergency Setting—A Case Report

Abstract

Aortic dissection with concurrent ST-elevation myocardial infarction (STEMI) is rarely reported. As the proportion of myocardial infarction is higher in the emergency setting compared to aortic dissection, the diagnosis of aortic dissection may be overlooked, and it can be potentially fatal. By using bedside available information, detailed history taking, and multimodality imaging in the emergency setting, it is possible to avoid a mistaken diagnosis. Here, we present a case of aortic aneurysm presenting with anterior STEMI. A 79-year-old woman was admitted to our emergency department with decreased consciousness. Shortly before the patient went unconscious, she had a short episode of dyspnea. Her ECG showed marked ST elevation in the anterior leads. However, her chest radiograph revealed mediastinal widening and a prominent aortic knob. Due to suspicion of aortic dissection from the chest radiograph and loss of consciousness, which may be a sign of malperfusion syndrome of aortic dissection, bedside handheld echocardiography was then performed. It revealed hypokinesis of anterior and anteroseptal walls, pericardial effusion, and dilated aortic root to ascending aorta with severe aortic regurgitation. The presence intimal flap can not be clearly excluded. Based on her imaging and clinical findings, aortic dissection was suspected and thrombolysis was postponed. The patient proceeded to undergo triple-rule-out computed tomography, from which the finding of ascending aortic aneurysm was noted, along with multiple stenosis of LAD (moderate-to-severe) and LCx (moderate), and there was no presence of false lumen. Acute aortic dissection should be considered a differential diagnosis in patients presenting with symptoms suggesting acute coronary syndrome. A suspected case of acute aortic dissection should necessitate further imaging studies. Therefore, multimodality imaging plays a vital role in the emergency setting, as it may avoid fatal consequences of misdiagnosis and mistreatment.