Wandering ST-Segment Elevation
A 52-year-old man with a history of surgical repair of an abdominal aortic aneurysm 9 years earlier had a sudden onset of chest and back pain. His primary physician diagnosed acute myocardial infarction on the basis of ST elevation in leads V2 and V3 (Figure 1A). ST segments in leads I and aVL became elevated 30 minutes later, when chest pain worsened (Figure 2B). On arrival at our hospital, the patient had a blood pressure of 70/50 mm Hg in both arms and a heart rate of 54 bpm. Both femoral and dorsal arteries were absent. An ECG showed ST elevation in leads I, aVL, and V5 to V6 (Figure 1C) and ST depression in V1 to V4. Left ventricular anterior and posterior wall motion was severely reduced on echocardiogram. In the cardiac catheterization laboratory, the ECG showed ST elevation in leads II, III, aVF, and V6 (Figure 1D) and further ST depression in precordial leads. Coronary angiograms showed an ostial stenosis of the right coronary artery (Figure 2A) and severe stenoses at the proximal left anterior descending coronary artery and the diagonal branch (Figure 2B). On repeat coronary angiography, arterial narrowing extended to the middle portion of the right coronary artery (Figure 2C), and the diagonal branch was occluded (Figure 2D). Intracoronary isosorbid dinitrate or diltiazem failed to dilate total or subtotal obstruction. Computed tomographic scans showed extensive aortic dissection involving the ascending to the descending thoracic aorta, the brachiocephalic trunk, the left common carotid artery, and the left subclavian artery (Figure 3).
It is sometimes difficult to diagnose acute aortic dissection extending into the coronary arteries and complicated by acute myocardial infarction. Wandering ST elevation may be a diagnostic clue for acute aortic dissection that extends into the coronary arteries, as seen in the present case.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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