Diagnostic Dilemma: Acute Aortic Syndrome vs. Acute Coronary Occlusion in the Emergency Department

BACKGROUND: Acute aortic syndrome (AAS) and acute coronary occlusion create a diagnostic dilemma in the emergency department (ED). We compared diagnostic delays, tools, and the impact of a paradigm shift from ST-elevation myocardial infarction (STEMI) to occlusion MI (OMI). STUDY OBJECTIVES: To compare diagnostic delays and tools for AAS and OMI and assess whether adopting an OMI-based paradigm rather than STEMI criteria may resolve this diagnostic dilemma by reducing diagnostic delays. METHODS: This retrospective chart review included all AAS, STEMI, and non-STEMI cases from June 2022 to June 2024 in two EDs. Cases were classified as OMI (acute culprit with thrombolysis in myocardial infarction 0-2 flow or peak troponin > 10,000 ng/L; or, without angiography, peak troponin > 10,000 ng/L with a new regional wall motion abnormality) or non-OMI. Charts were reviewed for the Aortic Dissection Detection Risk Score (ADD-RS). Triage electrocardiogram (ECG) levels were reviewed for STEMI by a blinded cardiologist and for OMI by blinded emergency physicians. RESULTS: Among 349 patients, 12 had AAS, 192 OMI, and 145 non-OMI. ADD-RS ≥ 1 had likelihood ratio (LR)- 0.1 but LR+ 3.9, and most had OMI. Triage ECG OMI signs doubled STEMI criteria sensitivity (39.1% vs. 16.7%), with no AAS cases. No AAS underwent catheterization laboratory activation, but 13 OMI (6.8%) had aortic computed tomography prior to angiogram, including one (7.7%) with STEMI ECG and five (38.5%) with OMI ECG. CONCLUSION: The AAS/OMI dilemma prioritizes AAS in spite of a low incidence, delaying OMI reperfusion. ADD-RS helps exclude AAS but does not distinguish it from OMI. OMI ECG signs double STEMI sensitivity with preserved specificity, which could reduce reperfusion delays. © 2025 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.