A 65-year-old man presented to our Emergency Unit with a history of chest pain of 12 h duration. The pain was dull, non-exertional, and also involved the epigastric and umbilical regions. Other review of systems was unremarkable. He reported similar episodes of chest discomfort lasting a few minutes, and associated with weakness in the prior few days. The prompt resolution of the symptoms caused him to underestimate the importance of these symptoms. Past medical history was negative for cardiopulmonary disease. There were no cardiovascular risk factors other than smoking. He took no medications. On admission, the patient was in no acute distress. Vital signs were blood pressure 110/60 mmHg, heart rate 104 beats/min, regular in rate and rhythm, oxygen saturation 99%. The jugular venous pressure (JVP) was not elevated, and there was no pulsus paradoxsus. Auscultation of the heart and lungs was unremarkable. Examination of other systems was normal; peripheral arterial pulses were present. The electrocardiogram (EKG) showed a normal sinus rhythm, ST-segment depression and T-wave inversion in anterior and lateral leads, and left ventricular hypertrophy. Laboratory tests were as follows: Troponin I 7.48 lg/L (normal reference range 0.00–0.15 lg/L), myoglobin 137 lg/L (normal reference range 12–70 lg/L), D-dimer 984 lg/L (normal reference range \225 lg/L) and NTproBNP 2,972 ng/L (normal reference range 0–900 ng/L). The chest X-ray study showed normal lung fields, with a normal cardiac silhouette and mediastinum. On the basis of clinical picture, the EKG, and the laboratory panel, an initial diagnosis of anterolateral non-ST elevated myocardial infarction was suggested. Because the patient also complained of abdominal pain, on abdominal physical examination, an unexpected finding at the auscultation was a continuous bruit in the periumbilical region. Therefore, an alternative diagnosis was hypothesized: aortic dissection with proximal involvement of a coronary ostium. An emergency abdominal echography was thus performed, and it showed an aortic aneurysm with a large communication to the inferior vena cava. Color Doppler confirmed this finding with the evidence of a turbulent continuous blood flow from aorta to vena cava through this patency. To better define this finding, a contrast-enhanced abdominal computed tomography (CT scan) was performed that revealed: an aneurysm of the descending aorta extending from the renal arteries to the iliac bifurcation, with parietal thrombosis and calcifications; a large aorto-caval fistula (ACF) just above the iliac bifurcation; and a thromboembolic occlusion of the segmentary branches of the pulmonary artery. The patient underwent an emergency aorto-iliac bypass, and a prosthetic graft from the left bypass branch to the common femoral artery. In the intensive care unit, he was treated with intravenous nitrates and fenoldopam, and started on ACE inhibitors. The postoperative course was characterized by a progressive amelioration of the clinical picture. Laboratory studies returned to normal. Subsequent cardiac monitoring revealed a normalization of the ST-segment depression and T wave inversion. Echocardiography showed a mildly dilated left ventricle (EDV 75 ml/m 2 ), preserved ejection fraction (53%), mild hypertrophy