ECG Findings and Management of Aortic Dissection

Diagnostic Considerations

The European Society of Cardiology recommends that ST-segment elevation with typical signs of acute transmural myocardial infarction occurs when the dissection blocks a coronary artery ostium, which can lead to catastrophic consequences if thrombolytic therapy is initiated 1
ST-segment depression indicates non-transmural infarction or coronary insufficiency, resulting from deteriorating hemodynamics in underlying coronary disease, dissection flaps blocking coronary ostia, or collapse of the true lumen during diastole 1
A normal ECG does not rule out aortic dissection, as the ECG may be entirely normal despite ongoing aortic dissection 1

The European Heart Society suggests that if aortic dissection is suspected based on clinical presentation, immediate imaging with CT angiography or transthoracic/transesophageal echocardiography should be obtained before any reperfusion therapy, with CT being the first diagnostic step in 61% of cases and TTE/TEE being used in 33% 2
Hemodynamic stabilization should be achieved by controlling heart rate to 60-80 beats/min with beta-blockers and targeting systolic blood pressure of 100-120 mmHg, with beta-blockers being used first and sodium nitroprusside added for severe hypertension 2
Transoesophageal echocardiography can be performed as the sole diagnostic procedure in hemodynamically unstable patients, and TEE visualizes the coronary ostia and first 2-3 cm of left coronary and 1-2 cm of right coronary artery 1, 3

The American College of Cardiology recommends that thrombolytics should never be administered based on ECG alone when aortic dissection is in the differential diagnosis, and pericardiocentesis before surgery may be harmful as it reduces intrapericardial pressure and causes recurrent bleeding 3
One high-quality imaging study is sufficient for decision-making, and obtaining multiple imaging modalities can be a waste of time 2

The European Heart Journal warns that thrombolytics, antiplatelet agents, and anticoagulation are absolute contraindications in patients with ST-segment elevation due to aortic dissection, as they can cause catastrophic hemorrhage into the dissection 4, 5, 6
When chest pain is present, it is impossible to differentiate myocardial ischemia from aortic dissection by ECG alone, and imaging must be obtained before administering thrombolytics, according to the European Heart Journal 4, 5, 7