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BMJ Case Rep. 2010; 2010: bcr08.2009.2155.
Published online 2010 March 4. doi:  10.1136/bcr.08.2009.2155
PMCID: PMC3028170
Learning from errors

Acute aortic dissection mimics acute inferoposterior wall myocardial infarction in a Marfan syndrome patient

Abstract

A 30-year old man with acute chest pain was diagnosed with acute inferoposterior wall myocardial infarction following electrocardiography. After a failed coronary angiography, an echocardiogram revealed an aortic intimal flap after which acute aortic dissection was diagnosed. The patient received a successful Bentall operation without immediate complication. Retrospective examination then confirmed the diagnosis of Marfan syndrome. This case demonstrates acute aortic dissection may mimic acute myocardial infarction.

Background

Acute aortic dissection is one of the leading causes of cardiovascular death. Correct and prompt diagnosis is an important key to the survival of patients. The main therapeutic option is surgical management. The major differential diagnosis is acute myocardial infarction, the treatment of which involves thrombolytic, anticoagulant and coronary revascularisation. Delayed diagnosis as well as misdiagnosis usually lead to catastrophic outcome. Here, we present a case where the initial diagnosis was acute myocardial infarction which was later changed to acute aortic dissection. The absence of risk factors for atherosclerosis as well as physical stigmata of Marfan syndrome provided the final clues to the diagnosis.

Case presentation

A 30-year-old man, previously healthy, was admitted to the non-trauma emergency department of a university based hospital due to sudden chest pain just 1 h before arrival with diaphoresis and a decreased level of consciousness. The patient was slowly responsive and physical examination revealed blood pressure of 80/30 mm Hg and heart rate of 40 beats/min. Lung auscultation was clear and no murmur was heard.

Investigations

Electrocardiogram (ECG) was done and showed pronounced ST elevation in leads II, III, aVF, V3R, V4R and deep reciprocal ST depression at leads I, aVl, V4–V6.

Differential diagnosis

The patient was diagnosed with acute ST elevation inferoposterior wall myocardial infarction with cardiogenic shock.

Treatment

A cardiologist was immediately consulted. Atropine, aspirin, clopidogrel, unfractionated heparin, dopamine and intravenous solution through a large bore catheter were given. A chest x-ray was performed. No pulmonary oedema or widened mediastinum were noticed.

Outcome and follow-up

On the table, coronary vessels could not be engaged. Bedside transthoracic echocardiography was later performed and demonstrated intimal flap in the ascending aorta down to the abdominal aorta. Physical examination was reviewed and showed discrepancy of blood pressure between right and left arms (right 96/46 mm Hg and left 123/31 mm Hg). The patient appeared to be tall (185 cm) and thin. He also had pectus carinatum deformity and arachnodactyly which suggested Marfan syndrome.

The patient underwent an emergency Bentall operation. The ascending aorta was dilated, 6 cm in diameter. The intimal flap was demonstrated in the ascending aorta through the descending aorta as limited by the median sternotomy approach. The aortic root was also dilated—annulo-aortic ectasia typical for a Marfan syndrome patient with moderate aortic incompetence. No anomalous or coronary artery dissection was observed, but the right coronary orifice was occluded by the false lumen. The patient survived with no immediate postoperative complications, and the ECG returned to normal postoperatively. Full anthropometric measurement secured the diagnosis of Marfan syndrome without familial history.

Discussion

Acute aortic dissection is one of the leading cardiovascular causes of death. Acute ST elevation myocardial infarction from ECG diagnosis can mask the correct diagnosis of aortic dissection.1 There are two previous reports of patients with a diagnosis of inferior wall myocardial infarction in whom acute aortic dissection was uncovered subsequently, when a coronary angiogram was technically unsuccessful when the catheter was inserted through the false lumen.2,3 Marfan syndrome is an autosomal dominant inherited disease with prominent cardiovascular, skeletal and ophthalmologic features. Aortic dissection is common and is the major cause of death in these patients, while acute myocardial infarction is rare and is associated with anomalous origin of coronary artery.4 This is the first case of aortic dissection presenting as acute inferoposterior wall myocardial infarction without anomalous or dissected coronary artery in a Marfan syndrome patient. The right coronary artery orifice was occluded by the false lumen as the previous non-Marfan syndrome patient.2 The non-specificity of the physical signs such as tall-thin body build might have led to the failure to recognise Marfan syndrome. The unfamiliarity of the primary doctor involved with the case at the emergency department also contributed to the misdiagnosis of this complication of Marfan syndrome.

Learning points

  • Aortic dissection is the foremost differential diagnosis in patients with suspected acute myocardial infarction with very low risk for atherosclerotic disease.
  • Physical examination suggests the most likely working diagnosis in patients with acute chest pain for developing a sequence of investigation to establish a diagnosis.
  • The presence of physical features of Marfan syndrome increases the likelihood of acute aortic syndrome over acute myocardial infarction.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Ohtani N, Kiyokawa K, Asad H, et al. Stanford type A acute aortic dissection developing acute myocardial infarction. Jpn J Thorac Cardiovascular Sur 2000; 48: 6972.
2. Li-Chin S, Ching-Hai K, Po-Yuan H, et al. Acute myocardial infarction caused by acute ascending aortic dissection. Acta Cardio Sin 2005; 21: 10510.
3. Kuei-Chuan C, De-Jinn W, Kwo-Chang U, et al. Acute aortic dissection developing acute myocardial infarction diagnosed by accidentally inserting the catheters into the false lumen during catheterization: a pitfall and rare image. Jpn Heart 2003; 44: 583–5. [PubMed]
4. Imperadore F, Grardini D, Vassanelli C, et al. Dissection of the ascending aorta complicated by acute myocardial infarction in a patient with Marfan syndrome and anomalous origin of the left circumflex artery. Description of a case. G Ital Cardiolo 1994; 24: 435–40. [PubMed]

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