Diagnostic Dilemma: Acute Aortic Syndrome vs. Acute Coronary Occlusion in the Emergency Department

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Acute Aortic Syndrome and Occlusion Myocardial Infarction (n=349). Intervention: Triage ECG occlusion myocardial infarction (OMI) signs vs. Triage ECG STEMI criteria. Primary outcome: Diagnostic sensitivity for occlusion myocardial infarction.

Q: What does this research mean for the field?

Triage electrocardiogram signs of occlusion myocardial infarction double diagnostic sensitivity for acute coronary occlusion compared with standard STEMI criteria (39.1% vs. 16.7%) while maintaining high specificity and avoiding misclassification of acute aortic syndrome. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Hisham Shokr; Amine Kaab; Mazen El-Baba; Jesse T. T. McLaren

doi:10.1016/j.jemermed.2026.08.004

August 21, 2026Journal of Emergency MedicineOpen Access

Diagnostic Dilemma: Acute Aortic Syndrome vs. Acute Coronary Occlusion in the Emergency Department

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Key result

Triage OMI ECG signs link to ~2-fold higher sensitivity for acute coronary occlusion vs. STEMI criteria.

n=349

Why the study?

Acute aortic syndrome and acute coronary occlusion create a diagnostic dilemma in the emergency department, complicating timely diagnosis and treatment.

Does an OMI-based ECG interpretation paradigm and ADD-RS clinical risk score improve diagnostic accuracy and reduce reperfusion delays compared to traditional STEMI criteria for differentiating AAS and OMI?

Key Points

To compare diagnostic delays and assessment tools for acute aortic syndrome and occlusion myocardial infarction, determining if adopting occlusion myocardial infarction criteria reduces delays.
Retrospective chart review of 349 patients (12 with acute aortic syndrome, 192 with occlusion myocardial infarction, and 145 non-occlusion cases) presenting to two emergency departments between June 2022 and June 2024.
Cases were classified using clinical definitions, troponin thresholds, and the Aortic Dissection Detection Risk Score (ADD-RS).
Triage electrocardiograms were evaluated for ST-elevation myocardial infarction (STEMI) criteria by a blinded cardiologist and for occlusion myocardial infarction (OMI) signs by blinded emergency physicians.
An ADD-RS of 1 or higher showed a negative likelihood ratio of 0.1 (95% CI 0.0-0.7) and a positive likelihood ratio of 3.9 (95% CI 3.0-5.0) for acute aortic syndrome, with most positive cases diagnosed with occlusion infarction.
Triage electrocardiogram occlusion signs doubled STEMI criteria sensitivity for all occlusion infarctions (39.1% vs. 16.7%) with preserved specificity (97.5% vs. 98.1%) and a positive likelihood ratio of 15.3 (95% CI 5.7-41.0).
No patients with acute aortic syndrome underwent catheterization laboratory activation, whereas 13 patients with occlusion infarction (6.8%) underwent computed tomography scans prior to angiography.

Study Design

Type

Observational (n=349)

Blinding

Outcome assessors blinded

Multicenter

Yes

Structured PICO

Does an OMI-based ECG interpretation paradigm and ADD-RS clinical risk score improve diagnostic accuracy and reduce reperfusion delays compared to traditional STEMI criteria for differentiating AAS and OMI?

P

Population

349 ED patients admitted with a diagnosis of acute aortic syndrome, STEMI, or NSTEMI evaluated retrospectively to compare diagnostic delays and accuracy of ECG interpretations.

E

Exposure

Diagnostic evaluation using the Aortic Dissection Detection Risk Score (ADD-RS) and triage ECG occlusion myocardial infarction (OMI) signs.

C

Comparator

Diagnostic evaluation using traditional ST-elevation myocardial infarction (STEMI) criteria.

O

Outcome

1) Delayed diagnosis (% AAS with door-to-CT time >12 hours and % OMI patients admitted as NSTEMI); 2) Altered diagnosis (% AAS patients with angiogram before diagnosis, and % OMI patients with CT before angiogram); and 3) Diagnostic accuracy (sensitivity/specificity and likelihood ratios) of clinical decision tools.

Main Result

Absolute Event Rate: 39.1% vs 16.7%

Adopting an OMI-based ECG interpretation paradigm over traditional STEMI criteria significantly increases the detection of acute coronary occlusion without mistakenly classifying acute aortic syndrome patients, thereby potentially reducing harmful delays in appropriate reperfusion therapy.

Limitations

Small sample size of patients with acute aortic syndrome limits generalizability.
Exclusion of patients with insufficient information to classify as OMI vs NOMI could affect ratios.
Only triage ECGs were captured, likely resulting in lower sensitivity than if serial ECGs were included.
Small sample size of AAS patients
Exclusion of patients with insufficient information to classify as OMI vs NOMI
Only triage ECGs were captured, not prior or repeat ECGs

Implication

May enhance occlusion MI detection in ED triage without AAS misclassification; hypothesis-generating for OMI adoption, needing prospective validation.

Abstract

BACKGROUND: Acute aortic syndrome (AAS) and acute coronary occlusion create a diagnostic dilemma in the emergency department (ED). We compared diagnostic delays, tools, and the impact of a paradigm shift from ST-elevation myocardial infarction (STEMI) to occlusion MI (OMI). STUDY OBJECTIVES: To compare diagnostic delays and tools for AAS and OMI and assess whether adopting an OMI-based paradigm rather than STEMI criteria may resolve this diagnostic dilemma by reducing diagnostic delays. METHODS: This retrospective chart review included all AAS, STEMI, and non-STEMI cases from June 2022 to June 2024 in two EDs. Cases were classified as OMI (acute culprit with thrombolysis in myocardial infarction 0-2 flow or peak troponin > 10,000 ng/L; or, without angiography, peak troponin > 10,000 ng/L with a new regional wall motion abnormality) or non-OMI. Charts were reviewed for the Aortic Dissection Detection Risk Score (ADD-RS). Triage electrocardiogram (ECG) levels were reviewed for STEMI by a blinded cardiologist and for OMI by blinded emergency physicians. RESULTS: Among 349 patients, 12 had AAS, 192 OMI, and 145 non-OMI. ADD-RS ≥ 1 had likelihood ratio (LR)- 0.1 but LR+ 3.9, and most had OMI. Triage ECG OMI signs doubled STEMI criteria sensitivity (39.1% vs. 16.7%), with no AAS cases. No AAS underwent catheterization laboratory activation, but 13 OMI (6.8%) had aortic computed tomography prior to angiogram, including one (7.7%) with STEMI ECG and five (38.5%) with OMI ECG. CONCLUSION: The AAS/OMI dilemma prioritizes AAS in spite of a low incidence, delaying OMI reperfusion. ADD-RS helps exclude AAS but does not distinguish it from OMI. OMI ECG signs double STEMI sensitivity with preserved specificity, which could reduce reperfusion delays.

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Cite This Study

Shokr et al. (2026) conducted an observational in Acute Aortic Syndrome and Occlusion Myocardial Infarction (n=349). Triage ECG occlusion myocardial infarction (OMI) signs vs. Triage ECG STEMI criteria was evaluated on Diagnostic sensitivity for occlusion myocardial infarction. Triage ECG signs of occlusion myocardial infarction doubled the diagnostic sensitivity for acute coronary occlusion compared to standard STEMI criteria (39.1% vs. 16.7%) with preserved specificity.

synapsesocial.com/papers/6ad1155900741cc3fba7d33c https://doi.org/10.1016/j.jemermed.2026.08.004

Topics

STEMI management

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Diagnostic Dilemma: Acute Aortic Syndrome vs. Acute Coronary Occlusion in the Emergency Department

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Diagnostic Dilemma: Acute Aortic Syndrome vs. Acute Coronary Occlusion in the Emergency Department

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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