Acute Coronary Syndrome vs Aortic Dissection
Acute Coronary Syndrome and Aortic Dissection are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Acute Coronary Syndrome vs Aortic Dissection at a glance
- Acute Coronary Syndrome: Spectrum of acute myocardial ischemia: unstable angina → NSTEMI → STEMI.
- Aortic Dissection: Intimal tear with blood propagating in the aortic media — Stanford A surgery, Stanford B medical unless complicated.
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Side-by-side comparison
| Feature | Acute Coronary Syndrome | Aortic Dissection |
|---|---|---|
| At a glance | Spectrum of acute myocardial ischemia: unstable angina → NSTEMI → STEMI. | Intimal tear with blood propagating in the aortic media — Stanford A surgery, Stanford B medical unless complicated. |
| Classic presentation | Levine's sign (clenched fist over sternum); cool/clammy skin; bradycardia in inferior MI.; Substernal chest pressure, tightness, or 'heaviness' (classic), often radiating to left arm, jaw, or back; Dyspnea, diaphoresis, nausea/vomiting; Atypical in women, elderly, diabetics: fatigue, epigastric pain, syncope, dyspnea without pain;… | Sudden, severe, tearing or ripping chest pain that radiates to the back/interscapular region (anterior chest for type A, between scapulae for type B); Maximum severity at onset (unlike crescendo MI pain); Migratory pain following dissection propagation; Syncope (especially type A — tamponade, severe AR); Focal neurologic deficit… |
| Workup / key labs | STEMI: ≥1 mm ST elevation in 2 contiguous limb leads OR ≥2 mm in 2 contiguous precordial leads (V2-V3 thresholds vary by age/sex), or new LBBB with clinical correlation. NSTEMI: positive troponin + ischemic symptoms ± ST depression / T-wave inversion. UA: ischemic symptoms with negative troponin.; Troponin I or T (high-sensitivity) at… | Stanford A: involves ascending aorta (regardless of distal extent) — surgical emergency. Stanford B: confined to descending aorta distal to the left subclavian — generally medical management. DeBakey I: ascending and descending; II: ascending only; III: descending only.; CBC, BMP, type and crossmatch (massive transfusion likely);… |
| Imaging | 12-lead ECG within 10 minutes of arrival — repeat every 15-30 min if initial nondiagnostic; Portable CXR (look for pulmonary edema, widened mediastinum to exclude aortic dissection); Bedside echo if hemodynamic instability or mechanical complication suspected | CT angiography of chest/abdomen/pelvis — first-line in hemodynamically stable patients (defines extent, identifies branch involvement, planning); Transesophageal echocardiography — bedside option for unstable patients or those who cannot undergo CT; MR angiography — alternative when iodinated contrast contraindicated; Transthoracic… |
| First-line treatment | Aspirin 325 mg chewed immediately; P2Y12 inhibitor loading dose: ticagrelor 180 mg, clopidogrel 600 mg, or prasugrel 60 mg (prasugrel only if known anatomy proceeding to PCI; avoid if age >75, weight <60 kg, or prior stroke/TIA); Anticoagulation: unfractionated heparin (preferred for PCI), enoxaparin, bivalirudin, or fondaparinux… | ABCs, 2 large-bore IVs, type and crossmatch, ICU admission; AGGRESSIVE blood pressure and heart rate control FIRST — target HR <60 and SBP 100-120 mmHg; IV beta-blocker FIRST to blunt reflex tachycardia: esmolol load 0.5 mg/kg then 50-200 mcg/kg/min, OR labetalol 10-20 mg IV bolus then infusion; AFTER beta-blockade established, add IV… |
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