A successfully thrombolysed acute inferior myocardial infarction due to type A aortic dissection with lethal consequences: the importance of early cardiac echocardiography

Acute myocardial infarction (AMI) usually results from an occlusive coronary thrombus at the site of a ruptured atherosclerotic plaque [1]. Reperfusion therapies such as primary percutaneous coronary intervention (PPCI) and thrombolysis are mandatory steps for reducing mortality and limiting the infarct size in patients with ST segment elevation myocardial infarction (STEMI). The greatest benefit occurs, if reperfusion therapy is initiated within the first hours from the onset of symptoms and there is no preference for either strategy, if these symptoms are present for less than 3 hours [2]. Clinically speaking, many conditions, such as acute aortic dissection, pericarditis, pulmonary embolism and myocarditis may mimic acute myocardial infarction. Thrombolysis in most of these situations is absolutely contraindicated due to its potentially lethal complications. Clinicians should always bear in mind the possibility that a type A aortic dissection (AAD) may mimic an AMI, which requires an urgent surgical repair without any delay.A 57-year-old woman, with a history of hypertension, was admitted to the emergency department of a rural non-PCI-capable Hospital due to an atypical, non-compressing, non-excruciating chest pain of recent origin (30 minutes) with radiation to the back. The patient was hemodynamically stable, with no peripheral pulse deficit. Auscultation of the heart revealed a 2/6 systolic murmur at the right base and apex and an early diastolic murmur at the right base without pericardial friction. The electrocardiogram (ECG) (Figure 1) was compatible with the diagnosis of a STEMI of the inferior wall. The doctor in charge decided to administer thrombolytic treatment with tenecteplase (TNK) (Metalyse？) without further delay. The patient's symptoms were partially relieved, while the pre-existing ST elevation did not seem to be completely normalized in the following 60 minutes. For this reason, she was referred to our hospital for rescue angioplasty [3]. When