Stemi or aortic catastrophe? a diagnostic minefield in an octogenarian

Abstract Background The clinical intersection of acute ST-segment elevation myocardial infarction (STEMI) and chronic aortic dissection (AD) represents a "diagnostic minefield," particularly in the fragile octogenarian population. Rapid reperfusion is the cornerstone of STEMI management, the presence of underlying aortic pathology introduces a catastrophic risk of hemorrhage or dissection extension if potent antithrombotics are initiated prematurely. This case underscores the paradox of managing ischemic signals in the shadow of a known aortic aneurysm, where traditional protocols may inadvertently become a liability. Case Illustration An 88-year-old female presented with a three-day history of crescendo, crushing chest pain radiating to the back. Despite a complex history of uncontrolled hypertension and a known aortic aneurysm, initial electrocardiography toward an acute anterior STEMI (ST elevation in V2–V4). However, the clinical picture was further complicated by a troponin I level of 50,000 ng/L and stage 5 chronic kidney disease (eGFR 3.19 mL/min/1.73m²), limiting the immediate use of contrast-heavy interventions. Advanced CT imaging eventually revealed an aortic arch aneurysm with suspected dissection and extensive thoracoabdominal atherosclerosis. The management required a high-stakes balance, prioritizing stabilization with cautious antiplatelet and beta-blocker therapy while navigating the contraindications posed by her profound renal impairment and aortic fragility. Conclusion In octogenarians, an ECG "classic" for STEMI can be a deceptive surrogate for aortic-related coronary compromise. This case highlights that in octogenarians with pre-existing aortic disease, clinical suspicion must outweigh protocolized speed. A multimodality imaging approach is essential to prevent lethal misapplication of ACS therapies in an evolving aortic catastrophe.Figure 1.Serial ECG, chest X-ray, and CT findings demonstrating aortic arch dilatation with suspected dissection (red arrows).