During the coronavirus disease 2019 (COVID-19) pandmic, more patients are presenting with complications late after acute myocardial infarction. We report the case of a 71-year-old man who delayed seeking medical care for 2 weeks, despite progressive shortness of breath, cough, and tactile fever, for fear of contracting COVID-19 in the hospital. Clinical and echocardiographic evaluation revealed a ventricular septal rupture secondary to acute myocardial infarction. The patient underwent urgent cardiac catheterization, followed by successful saphenous vein grafting to the left anterior descending coronary artery and open surgical repair of the ventricular septal rupture with a bovine pericardial patch. This case highlights a potential long-lasting negative effect that the COVID-19 pandemic will have on the care-seeking behavior and health of patients with acute cardiovascular disease.

INTRODUCTION: Nearly 30% of aortic dissection (AoD) cases are misdiagnosed. Suspicion is highest in patients presenting with both chest and back pain but back pain is only seen in 53%. Most present with hypertension and are male. Predictors of inhospital death for patients with type A AoD include female sex, abrupt onset of pain, new Q waves and/or ST segment deviation, and hypotension. CASE PRESENTATION: A 66-year-old woman with a history of hypertension presented with sudden anterior chest pain. Electrocardiogram (EKG) was diagnostic for anterior ST elevation myocardial infarction (STEMI). The patient was hypotensive and intermittently in heart block. She was loaded with aspirin, clopidogrel, and atorvastatin, started on a dopamine drip, and taken for cardiac catheterization. An intraaortic balloon pump (IABP) was inserted but aortography revealed the presence of an acute dissection. IABP was immediately discontinued. The patient underwent ascending aorta and aortic valve repair. Despite surgery, cardiogenic shock persisted, multi-organ failure ensued, and the patient died. DISCUSSION: Due to this patient's presentation as an anterior STEMI, she was treated with the acute coronary syndrome algorithm. It is unlikely that avoidance of antiplatelets, dopamine, and/or IABP would have altered her course given her high risk features. Nevertheless, AoD must be considered in the differential of STEMI. An aortogram should be performed prior to IABP use in cases with high clinical suspicion. CONCLUSIONS: This patient presented as an unusual case of anterior STEMI secondary to left main disease from an aortic dissection. This case highlights the STEMI differential diagnosis and application of aortography prior to IABP use.

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Only 6% of aortic dissections (AoD) present with acute congestive heart failure (CHF). These patients may have an atypical presentation, including hypotension and absence of pain. CHF in the presence of AoD is due to aortic regurgitation and/or coronary hypoperfusion. CASE PRESENTATION: A 31-year-old woman with no medical history presenting with cough and nausea/vomiting was found to be hypoxic and hypotensive. Electrocardiogram (EKG) demonstrated diffuse ST segment depressions. Labs were notable for leukocytosis, hyponatremia, and acute kidney injury, as well as elevated cardiac troponin and probrain natriuretic peptide. Cardiology was consulted after point of care ultrasound showed reduced systolic function. Urgent transthoracic echocardiogram (TTE) showed a large dissection flap prolapsing across the aortic valve and causing severe aortic regurgitation. The patient was also noted to have biventricular failure with moderate mitral regurgitation. Computed tomography angiography (CTA) confirmed the presence of an extensive Type A AoD. The patient underwent urgent aortic valve, root, and arch replacement with improvement in left ventricular function. Later analysis revealed a FBN1 genetic mutation associated with Marfan Syndrome. DISCUSSION: This case illustrates an unusual presentation of AoD as CHF in a young patient without pain. Like the patient in this case, individuals presenting with AoD and CHF are more likely to present without chest pain and in shock, as well as to have a valvular abnormality and a Stanford type A dissection. CHF can lead to a delay in surgical intervention, although it did not in this case. CONCLUSIONS: AoD must be considered in the differential diagnosis of unexplained CHF, even in the absence of pain, in order to minimize surgical delay and mortality.