Although it is uncommon, acute aortic dissection (AD) is a challenging clinical emergency that develops rapidly, with an often fatal outcome. The typical presentation is characterized by an acute onset of severe chest pain, but clinical manifestations can vary and are diverse, and what were previously considered to be classic symptoms and signs are often absent. Therefore, a high clinical index of suspicion is necessary. We herein describe a patient with chest pain initially diagnosed as acute coronary syndrome (ACS), but later found to be an acute aortic dissection.
A 59-year-old female with a past medical history of hypertension, hyperlipidemia, and transient ischemic attack 5 years prior, with a 30 pack-year smoking history, maintained her usual state of health until waking with chest pain described as a retrosternal pressure-like sensation and discomfort felt all over the precordial area. Symptoms were episodic and lasted for 15-20 minutes each time, prompting her to seek help by visiting an urgent care center. An electrocardiogram (ECG) done at the urgent care center showed normal sinus rhythm (NSR) with T-wave inversion in the precordial leads. She was immediately transferred to our emergency department. In the hospital, her chest pain continued intermittently, but resolved with nitroglycerin. The patient also had minimal diaphoresis but no palpitations, shortness of breath, dizziness, or lightheadedness. No other significant findings were found on physical examination. Blood pressure was found to be similar in both upper extremities. An electrocardiogram (ECG) showed similar T-wave inversions in precordial leads and her intial troponin was negative. The patient was managed as unstable angina, and considering her significant risk factors for coronary artery disease, the plan was to perform a left heart catheterization (LHC) to further evaluate her coronary anatomy. LHC showed mild, nonobstructive coronary artery disease (Figures 1-3) and her left ventricular function on a LV gram was normal (Figure 4). However, following the procedure, the patient continued to have intermittent chest pain and a decision was made to perform a computed tomography angiography (CTA) of the chest. The CTA showed an extensive dissection of the ascending thoracic aorta extending to the level of the aortic valve and throughout the visualized portion of the upper abdominal aorta. A prominent dissection flap was visible, extending into the proximal aspect of the left subclavian, left common carotid, and right brachiocephalic arteries, and dilatation of the ascending thoracic aorta to slightly greater than 5 cm, tapering to a more normal caliber through the arch, and thus diagnosed as a Type A aortic dissection with aneurysmal dilatation of the ascending thoracic aorta (Figures 5-9). Cardiothoracic surgery was immediately consulted, and the patient underwent emergent ascending and hemiarch aortic replacement using a 26 mm Gelweave graft (Terumo). Postoperatively, the patient’s chest was left open as she developed minimal bleeding, then subsequently closed after 2 days. Her clinical status improved gradually and the patient was discharged home a week after the surgery.
Acute aortic dissection is a rare, life-threatening condition of the aorta and is associated with significant morbidity and mortality. The most lethal of dissections involves the ascending aorta and is commonly referred to as acute type A aortic dissection (ATAAD). Unless the prompt surgical repair is performed, patients usually die from complications related to the dissection, including rupture of the aorta, pericardial tamponade, aortic regurgitation, end-organ malperfusion, or acute heart failure.1,2 The Stanford classification divides aortic dissection into types A and B.3 Type A dissections involve the ascending aorta, eventually progressing to the distal aorta. Type B dissections originate at the level of the descending aorta. Two-dimensional transthoracic echocardiography (TTE) is also helpful as an initial screening test, specifically in patients with ATAAD, with a sensitivity ranging from 78-100% in those cases.4 Diagnosis of an aortic dissection relies solely on imaging examinations, including echocardiography and CTA. Among these techniques, the TTE demonstrates a sensitivity of 77 to 80% and a specificity of 93 to 96% for the identification of a proximal aortic dissection.5 ATAAD is characterized by a sudden, intense chest pain sometimes described as “ripping” or “tearing”, usually located retrosternal or substernal, and may propagate in a distal or proximal direction as the dissection evolves. ECG may show signs of cardiac ischemia or non-specific ST and T-wave alterations, and occasionally coronary flow may be impaired due to coronary ostia dissections.6 Prompt diagnosis based on early suspicion of dissection is mandatory for successful treatment. Conventional chest x-ray can show a wide mediastinum, which is not specific for diagnosis. The quickest and most accurate method, however, of confirming the diagnosis is CT scanning of the aorta.7 Coronary angiography is not indicated as a primary diagnostic method for ATAAD, but sometimes it is detected at coronary angiography when ACS is initially suspected. In highly specialized centers, coronary angiography is performed as part of a complete work-up done in a hybrid suite immediately before open surgery, as up to 30% of ATAAD patients have unknown but significant coronary artery disease that may warrant treatment and affect outcomes.8 The morbidity rate of ATAAD is 6 cases per 100,000 person-years.9 Approximately 7% of patients with aortic dissection have a concomitant acute myocardial infarction (AMI).5 Nevertheless, in patients with AMI secondary to aortic dissection, the omission diagnostic rate of aortic dissection has been as high as 30%.10 Imaging studies for ST-elevation myocardial infarction (STEMI) patients may not be done initially due to the possibility of increasing the door-to-balloon time in the emergency setting. Guidelines for patients with STEMI dictate that antiplatelet therapy should be given at the time of first medical contact, and patients should be sent to the cardiac catheterization laboratory for the interventional diagnosis and treatment as soon as possible.11 However, for patients with STEMI, the missed diagnosis of aortic dissection could be catastrophic, because the antiplatelet therapy and the cardiac catheterization, the therapeutic approaches for AMI, are exactly two absolute contraindications to aortic dissection treatment, as both can aggravate bleeding, broaden the range of the dissection, and even increase the risk of death.
ATAAD is a highly deadly cardiovascular emergency. Acute surgical treatment is indicated for all patients, except for those who are moribund or severely comorbid.
1Saint Peter’s University Hospital, New Brunswick, New Jersey; 2University of Scranton, Scranton, Pennsylvania; 3Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Monarch Shah, MD, at email@example.com
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