GS

54 year old male was brought into emergency department with chest pain as ST Elevation Myocardial Infarction (STEMI) alert. He had a background history of hypertension. He complained of chest pain the evening before which got worse the next day. His vitals were: BP 164/86, oxygen sats 94% on room air, HR 66/min and RR 20/min. His chest was clear to auscultation and his heart sound was dual with no murmur. His ECG showed inferior STEMI. He was loaded with 300mg of aspirin by the paramedics crew.

Patient was transferred urgently to the catheterization lab. Ultrasound guided vascular access was obtained in the right femoral artery. JL-4 Catheter was used but noted to be catching in the ascending aorta. JR-4 guide into aortic root withnon-selective shot suggesting aortic dissection - filling the right coronary artery therefore in the false lumen. This is then confirmed with pigtail aortogram where the true lumen is shown and filling the left main artery. Patient had ongoing hypertension. Glyceryl trinitrate infusion was started with gradual titration to 25mcg/min. Our Centre did not have on site cardio-thoracic surgery so a tertiary centre was alerted and high acuity transport was organized. Bedside transthoracic echocardiogram was done and excluded any significant pericardial effusion. AV dissociation was noted intermittently, pacing wire was inserted via right femoral vein and set at VVI mode at 60 beats per minutes. Patient was then transferred to ICU and intubated for transport to a tertiary centre. Patient was transferred to a cardiothoracic centre but unfortunately arrested on the CT table. Attempted Cardio-Pulmonary Resuscitation was performed but he did not have return of spontaneous circulation and passed away before he could get to operating theatre.

In conclusion, clinicians need to have a high index of suspicion for aortic dissection in patients with chest pain. Myocardial infarction resulted from functional coronary artery occlusion where the dissection flap occluded the ostium of right coronary artery. Prompt diagnosis could avoid unnecessary anticoagulation that may result in fatal outcomes.