European Heart Journal Advance Access originally published online on October 30, 2007
European Heart Journal 2008 29(2):277-278; doi:10.1093/eurheartj/ehm498
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Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology
Institute of Cardiology
University of Bologna and S. Orsola-Malpighi Hospital
via Massarenti 9
40138 Bologna
Italy
Tel: +39 051349858
Fax: +39 051344859
Email: claudio.rapezzi{at}unibo.it
Institute of Cardiology
University of Bologna and S. Orsola-Malpighi Hospital
Bologna
Italy
Institute of Cardiology
University of Bologna and S. Orsola-Malpighi Hospital
Bologna
Italy
‘Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology’ recently published in European Heart Journal1 rightly dedicates space to the pitfalls that can be encountered when reading presentation ECGs. However, we wish to draw attention to what we think is an important omission. No reference is made in this context to acute aortic syndrome (AAS)—a condition in which inappropriate administration of aggressive anti-thrombotic therapy may have catastrophic consequences.2 It is common knowledge that AAS can occasionally cause STEMI via coronary artery dissection. However, in recent years, accumulating evidence indicates that ischaemic alterations, often interpretable as non-STEMI, are rather common at presentation of AAS. In a large international registry, ischaemic alterations were observed in 
15% of all AAS patients3 and in as many as 21% of those with Stanford type A.4 Ischaemic ECGs can occur in both Stanford subtypes (and in intramural haematomas as well as classic aortic dissection).3,5 Ischaemic presentation ECGs appear to be more common in complicated forms of AAS.2,5 In Stanford type A disease, such ECGs have been associated with higher in-hospital mortality.4,5 Remarkably, in both Stanford types, ischaemic ECGs seem more often to be characterized by non-STEMI features.2,5 Of note, the difficulties in recognizing AAS in patients with chest pain may be amplified by the finding of raised troponin levels.5 In AAS, ischaemic ECGs can stem from very different substrates, including interference by the aortic flap in the coronary flow (at the ostial level), left ventricular pressure/volume overload, pericardially mediated electrical abnormalities, pre-existing repolarization abnormalities, and global myocardial ischaemia either due to low cardiac output or due to shock.2,5 Underlying coronary artery disease may in turn amplify the effects of any of these determinants. Taken together, these observations indicate that the issue of differential diagnosis between acute coronary and aortic syndromes cannot be confined to the physical examination phase. The consistency of the available evidence2–5 highlights the importance that clinicians should be aware that presence of an ischaemic ECG pattern (whether non-STEMI or STEMI) does not in any way exclude the diagnosis of AAS.
Funding to pay the Open Access publication charges for this article was provided by the Fanti Melloni Foundation, University of Bologna, Italy.
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