"Left Main" Pattern Electrocardiogram: A Diagnostic Trap for Cardiologists
Grace Hoi Ting Kwok1, Kevin Ong2, Wai Kin Chi3
1Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
Insights
Acute aortic dissection can mimic left main coronary artery occlusion on ECG, leading to misdiagnosis. This case highlights the importance of considering aortic dissection in patients with concerning ECG findings, even without coronary artery blockage.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Diagnostic Imaging
Background:
- Acute Stanford type A aortic dissection presents a diagnostic challenge, potentially mimicking left main coronary artery occlusion on electrocardiography (ECG).
- This mimicry is critical as the management strategies for these two conditions are fundamentally different.
Background:
Acute Stanford type A aortic dissection may mimic left main coronary artery occlusion on electrocardiography (ECG) yet requires fundamentally different management.
Case Summary:
A 63-year-old woman presented with sudden chest pain, collapse, and cardiogenic shock. ECG showed ST-segment elevation in aVR with diffuse precordial ST-segment depression, suggesting left main coronary occlusion and prompting consideration of urgent coronary angiography. Examination revealed severe aortic regurgitation and a carotid intimal flap. Echocardiography and computed tomography aortography confirmed extensive Stanford type A dissection from the aortic root to the renal arteries with patent coronary ostia.
Discussion:
This case shows that global subendocardial ischemia from acute severe aortic regurgitation, shock, and malperfusion can reproduce a "left main" ECG pattern without epicardial coronary occlusion.
Take-Home Messages:
When ECG suggests left main coronary artery occlusion, meticulous clinical assessment and urgent imaging are essential to exclude aortic dissection. The Aortic Dissection Detection Risk Score is a useful tool for identifying high-risk features of acute aortic dissection.
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