Diagnostic dilemma: acute aortic syndrome vs acute coronary occlusion in the emergency department

BACKGROUND acute aortic syndrome (AAS) and acute coronary occlusion are a diagnostic dilemma in the emergency department (ED). We compared their delays, diagnostic tools, and the impact of a paradigm shift from ST-Elevation MI (STEMI) to occlusion MI (OMI). METHODS this retrospective chart review from two EDs included all AAS, STEMI or Non-STEMI from June 2022 to June 2024. STEMI/Non-STEMI were classified as OMI (acute culprit with either TIMI 0–2 flow or peak troponin > 10,000 ng/L; or if no angiogram then peak troponin > 10,000 ng/L with new regional wall motion abnormality) or Non-OMI. Charts were reviewed for Aortic Dissection Detection Risk Score (ADD-RS). Triage ECGs were reviewed for STEMI interpretation by a blinded cardiologist, and OMI interpretation by blinded emergency physicians. RESULTS 349 patients included 12 AAS, 192 OMI and 145 Non-OMI. ADD-RS ≥ 1 had LR- 0.1 but only LR + 3.9, and most ADD-RS ≥ 1 had OMI. Triage ECG OMI signs doubled STEMI criteria sensitivity (39.1% vs 16.7%), and none had AAS. No AAS had cath lab activated, but 13 OMI (6.8%) had aorta CT before angiogram, including one (7.7%) STEMI ECG and 5 (38.5%) OMI ECG. CONCLUSIONS the AAS/OMI diagnostic dilemma prioritizes AAS despite its low incidence, leading to OMI reperfusion delays. ADD-RS helps exclude AAS but not differentiate it from OMI. OMI ECG signs double STEMI sensitivity with preserved specificity, which could reduce reperfusion delays with a low likelihood of missing AAS.