Acute Aortic Dissection Masquerading as Acute Coronary Syndrome: Is Echocardiogram Mandatory before Primary Percutaneous Coronary Intervention?

A 58-year-old hypertensive man was admitted with severe central chest pain and palpitation. His electrocardiogram (ECG) showed fast atrial fibrillation with features suggestive of left main coronary artery occlusion. He was taken to the Cath-lab but surprisingly, coronary angiogram (CAG) showed no stenosis. Meanwhile, other labs showed high D-dimer and lactate. Hence, bedside Transthoracic echocardiography (TTE) was carried out and showed dissecting flap in the ascending aorta. Immediately, a CT (Computed Tomography) was arranged and it revealed Stanford Type-A Aortic Dissection (AD). Then urgently, he was taken for surgery but unfortunately, he died after long surgical procedure. Here, the misleading factors were that his presentation and ECG changes were so typical of acute coronary syndrome (ACS) that heading us to think about coronary artery disease (CAD). Therefore, the intriguing question: is a bedside echocardiography before shifting to Cath-lab could have given the clue for early detection of AD.