13Myocardial infarction or aortic dissection? It could be both

Abstract

Introduction:The aortic dissection(AD) is a rare cardiovascular emergency that requires an early and accurate diagnosis and treatment for survival.When untreated,about 33% of patients die within the first 24h and 50% die within 48hs.The2-week mortality rate approaches 75% in pt with undiagnosed ascending AD.Case report:A 68 y.o female patient presented to the ER due to strong heavy chest pain started abruptly 6hours prior to admission and high sBP∼200mmHg.The pt had HTN and was on antihypertensives taken irregularly.On initial assessment she was pale and tachycardic(110/min).Periferic pulses present.The ECG had signs of lateral ischemia and the TroponinI level was elevated. A diagnose of ACS was made and she was admitted in the ICU.Transthoracic echocardiography revealed antero-lateral wall motion anomalies and a prominent atrial septal aneurism(IAS)-no communication.She was referred to the cath lab for an emergency angiography confirming a multivessel CAD(LAD50%stenosis, RCA50%stenosis and D1 75-90%stenosis) treated with PPCI(1DES on D1).The procedure went well,no remarkable findings.She was put on triple therapy (enoxaparin, aspirin and clopidogrel).The next day a hematoma at the femoral site of puncture and a drop in the Hb level (from 11 to 8.8 g/dl)was noticed.She received a unit of blood.Peripheric pulses were present.The Doppler US confirmed the hematoma but no pseudoaneurism.Then the pt developed AF,received Amiodarone iv and continued it orally.2 days later an ischemic stroke of the temporo-frontal region was confirmed by a head CT scan.A week after MI she was transferred to the cardiology ward.A new TTE showed hypokinesia of the lateral wall,preserved EF,hypertrophic LV,dilated ascending Ao(46 mm)and the prominent aneurysm of IAS.The pt was in good condition,no chest pain since the PCI,sinus rhythm,controlled BP and present peripheric pulses. A TEE was scheduled because of the IAS and performed on the 11th day showing ascending AD from the STjunction to the abdominal Ao with an aspect of a double lumen and hematoma,without a visible entry site,no communication through the IAS and mild pericardial effusion. An emergency CTscan confirmed AD typeA starting from the ST junction(max diam 64mm) progressing towards the left iliac artery,intramural hematoma of the ascending part,an entry site at the aortic arch,supra aortic vessels originating from the true lumen-no dissection.A cardiac surgery team suggested conservative treatment.LMWH and aspirin were withdrawn.She was discharged a day later against medical advice.Conclusion:We present a rare case of MI treated successfully with PPCI and an incidental diagnose of acute AD through TEE and CTscan.PCI only is not always enough in a patient with angina.The triple therapy may have accelerated the antegrade and retrograde propagation of the initial tear.Was the withdrawal of LMWH a good decision?Could have been a coronary CT scan performed at admission a better tool for diagnosing the AD? (Figure Presented).