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If a patient presents with chest pain, beware: it might not be ACS but rather Aortic Dissection.

Writer: MaytaMayta

Accurately distinguishing between STEMI and aortic dissection, which both present with severe chest pain but require vastly different treatments, is critical for appropriate and potentially life-saving management.

As medical professionals, accurately differentiating between conditions with similar presentations but vastly different management strategies is crucial. One such clinical problem is distinguishing between ST-segment elevation myocardial infarction (STEMI) and aortic dissection, both of which can present with severe chest pain but require distinctly different treatments. This blog post aims to elucidate the key aspects of these conditions to aid in accurate diagnosis and appropriate management.

Clinical Presentation

STEMI:

  • Symptoms: STEMI typically presents with central chest pain, which may radiate to the arms, neck, or jaw. The pain is often described as a crushing or pressure-like sensation. Accompanying symptoms can include shortness of breath, diaphoresis, nausea, and vomiting.

  • ECG Findings: The hallmark of STEMI on an ECG is ST-segment elevation in two or more contiguous leads, which indicates acute myocardial injury.

  • Cardiac Biomarkers: Elevated levels of cardiac enzymes, such as troponins, confirm myocardial damage.

Aortic Dissection:

  • Symptoms: Aortic dissection often presents with sudden, severe chest pain described as a tearing or ripping sensation, which can radiate to the back, between the shoulder blades. Patients may also report differential blood pressure between arms, neurological deficits, or abdominal pain depending on the dissection's extent.

  • Imaging: A widened mediastinum on chest X-ray raises suspicion for aortic dissection. Definitive diagnosis is typically made with CT angiography, which provides detailed images of the aorta.

Diagnostic Approach

Initial Assessment:

  • Vital Signs and Physical Examination: Evaluate the patient’s hemodynamic stability, perform a thorough physical exam, and look for signs of differential blood pressure in the limbs, a new murmur (aortic regurgitation), or neurological symptoms.

  • Bedside Ultrasound: Useful for detecting pericardial effusion, which can occur with aortic dissection.

Laboratory and Imaging Studies:

  • ECG and Cardiac Biomarkers: Essential for diagnosing STEMI.

  • Chest X-ray: Look for a widened mediastinum suggestive of aortic dissection.

  • CT Angiography: The gold standard for diagnosing aortic dissection.

Management Strategies

STEMI:

  • Immediate Management: Administer antiplatelet therapy (aspirin, clopidogrel) and anticoagulation (heparin). Provide oxygen if hypoxic and consider beta-blockers if there are no contraindications.

  • Reperfusion Therapy: Primary percutaneous coronary intervention (PCI) is preferred. If PCI is unavailable, thrombolysis with agents like alteplase may be necessary.

  • Ongoing Care: Monitor for complications such as arrhythmias and heart failure. Reassess with follow-up ECGs and biomarkers.

Aortic Dissection:

  • Immediate Management: Control blood pressure aggressively with IV beta-blockers (e.g., labetalol) to reduce shear stress on the aorta. Provide pain relief with opioids.

  • Surgical Intervention: For Type A dissections, emergency surgery is usually required. Type B dissections may be managed medically unless complications arise.

  • Transfer and Monitoring: Transfer to a center with cardiovascular surgical capabilities if needed. Continuous hemodynamic monitoring is essential.

Clinical Pearls

  • Rapid Differentiation is Critical: While both STEMI and aortic dissection can present with chest pain, the nature of the pain, physical findings, and initial imaging can provide crucial clues.

  • Avoid Premature Anticoagulation: In cases where aortic dissection is a possibility, delay anticoagulation until the diagnosis is ruled out by imaging, as it can exacerbate dissection.

  • Use a Multimodal Approach: Combine clinical assessment, ECG, cardiac biomarkers, and appropriate imaging studies to arrive at an accurate diagnosis.

By understanding the subtle differences and employing a systematic approach to evaluation and management, we can ensure that patients receive the appropriate and potentially life-saving treatment.

Stay tuned for more insights and discussions on critical differential diagnoses in emergency medicine. Your expertise and continuous learning are vital in providing the best care for your patients.

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Message for International Readers
Understanding My Medical Context in Thailand

By Uniqcret, M.D.
 

Dear readers,
 

My name is Uniqcret, which is my pen name used in all my medical writings. I am a Doctor of Medicine trained and currently practicing in Thailand, a developing country in Southeast Asia.
 

The medical training environment in Thailand is vastly different from that of Western countries. Our education system heavily emphasizes rote memorization—those who excel are often seen as "walking encyclopedias." Unfortunately, those who question, critically analyze, or solve problems efficiently may sometimes be overlooked, despite having exceptional clinical thinking skills.
 

One key difference is in patient access. In Thailand, patients can walk directly into tertiary care centers without going through a referral system or primary care gatekeeping. This creates an intense clinical workload for doctors and trainees alike. From the age of 20, I was already seeing real patients, performing procedures, and assisting in operations—not in simulations, but in live clinical situations. Long work hours, sometimes exceeding 48 hours without sleep, are considered normal for young doctors here.
 

Many of the insights I share are based on first-hand experiences, feedback from attending physicians, and real clinical practice. In our culture, teaching often involves intense feedback—what we call "โดนซอย" (being sliced). While this may seem harsh, it pushes us to grow stronger, think faster, and become more capable under pressure. You could say our motto is “no pain, no gain.”
 

Please be aware that while my articles may contain clinically accurate insights, they are not always suitable as direct references for academic papers, as some content is generated through AI support based on my knowledge and clinical exposure. If you wish to use the content for academic or clinical reference, I strongly recommend cross-verifying it with high-quality sources or databases. You may even copy sections of my articles into AI tools or search engines to find original sources for further reading.
 

I believe that my knowledge—built from real clinical experience in a high-intensity, under-resourced healthcare system—can offer valuable perspectives that are hard to find in textbooks. Whether you're a student, clinician, or educator, I hope my content adds insight and value to your journey.
 

With respect and solidarity,

Uniqcret, M.D.

Physician | Educator | Writer
Thailand

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