AORTIC DISSECTION

A CASE OF ATYPICAL PRESENTATION AND VALUABLE LESSON TO LEARN

Chow M.Y1, Jonah Seeni John2, Khoo T.S3, Mohamad Hamim Mohamad Hanifah1
1Emergency & Trauma Department, Labuan Hospital, Malaysia
2Surgical Department, Labuan Hospital, Malaysia
3Medical Department, Labuan Hospital, Malaysia
MINISTRY OF HEALTH
MALAYSIA

INTRODUCTION
INTRODUCTION
Aortic dissection is a relatively uncommon emergency condition where there is a separation of the inner layer of the aorta. Patient
usually presented with the classic 'tearing' and 'excruciating' chest pain or pain between the shoulder blades. In some cases, the
symptoms may mimic acute coronary syndrome, which poses a challenge in diagnosis and initial treatment.
CASE PRESENTATION
A 60-year-old gentleman with known case of hypertension , Patient was subsequently proceeded with urgent CT
diabetes mellitus, and chronic heart failure presented to our angiography, and it was reported to have a extensive Stanford A
Emergency Department with sudden onset of epigastric pain. The thoracic aortic dissection with extension into the aortic branches.
pain was described as pricking in nature with no relieving factors. Patient was then referred to tertiary centre via air ambulance for
Pain score given as 6 at rest. cardiothoracic surgical intervention.

Upon examination, there was mild epigastric tenderness

without rebound and guarding. Auscultation of lungs revealed
bibasal crepitation. ECG done was suggestive of non-ST elevation
acute coronary syndrome (ACS), thus was started on double
antiplatelet and sublingual nitrate. Patient claim symptoms
improved with initial medication.

Figure 1 : ECG
revealed right
bundle branch
block ( RBBB ) with
ST depression over
lead I, II , aVL.

However, further chest

radiograph noted widening of
mediastinum which prompts
the suspicion of aortic
dissection. Subsequent
examinations noted unequal
pulse volume over bilateral
radial pulse. Measurement of
blood pressure over bilateral
upper limb noted to have
obvious discrepancy.
Otherwise, blood investigations Figure 2 : Plain chest Figure 3 : The serial CT angiographic view of the patient showing dissection flaps ,
radiograph shows widened indicated by arrows, from the aortic arch extending towards the abdominal aorta.
revealed normal results and
mediastinum and cardiomegaly
cardiac markers were not
raised.

DISCUSSION AND LESSON LEARNT

In patients with acute pain over chest or epigastrium, a few
Clinical suspicion is the most important step in diagnosing
important differential diagnosis should be kept in mind. The
aortic dissection. Suspicion should arise if :
incidence of ACS is relatively high and commonly encountered in
• there is significant discrepancy of bilateral arm blood pressure.
emergency department compared to aortic dissection, and the
• there is presence of radio-radial delay or radio-femoral delay.
diagnosis of ACS depends mainly on clinical manifestations, the
• there is unequal pulse volume over bilateral radial pulse.
ECG, and cardiac enzyme level. This drives the clinicians to pay
• Widening of mediastinum in chest radiograph.
more attention to ACS , and tends to neglect the differential
diagnosis of aortic dissection. In this case, patient was presented The common ECG abnormality in patient with aortic
with atypical symptoms which suggestive of ACS, which was dissection is ST-segment depression, which may also mimic those
further ‘convinced’ by ECG findings. seen in ACS. Thus, the diagnosis of aortic dissection should be
Misdiagnosis of Aortic Dissection as ACS can be disastrous. considered and confirmed with methods which are non-invasive
This is because the antiplatelet and anticoagulant therapy , which and easily available such as bedside echocardiogram or plain chest
are the therapeutic approach in ACS , are absolute radiograph.
contraindications to aortic dissection, as they can aggravate
bleeding, broaden the range of the dissection, and even increase
the risk of death.
CONCLUSION
Although aortic dissection is a catastrophic condition with high mortality and requires prompt surgical treatment but in some cases it
may be misdiagnosed as acute coronary syndrome. A high level of suspicion remains key for prompt diagnosis and management.
ACKNOWLEDGEMENT
We would like to express our gratitude to our Director General, Ministry of Health, Malaysia for permission to publish this poster.
NMRR-19-704-47780
REFERENCES
[a] Ansari-Ramandi MM, Alemzadeh-Ansari MJ, Firoozi A. Acute Type A Aortic Dissection Missed as Acute Coronary Syndrome. J Clin Diagn Res 2016;10(5):OD33–OD34.
doi:10.7860/JCDR/2016/18640.7854
[b] Wang D, Zhang LL, Wang ZY, Zhang ZY, Wang Y. The missed diagnosis of aortic dissection in patients with acute myocardial infarction: a disastrous event. J Thorac Dis. 2017;9(7):E636–E639.
doi:10.21037/jtd.2017.06.103
[c] Hirata K, Wake M, Kyushima M, Takahashi T, Nakazato J, Mototake H, Tengan T, Yasumoto H, Henzan E, Maeshiro M, Asato H. Electrocardiographic changes in patients with type A acute aortic
dissection. Incidence, patterns and underlying mechanisms in 159 cases. J Cardiol. 2010 Sep;56(2):147-53. doi: 10.1016/j.jjcc.2010.03.007.
[d] Kuan PX, Tan PW, Jobli AT, Norsila AR. Discrepancy in blood pressure between the left and right arms - importance of clinical diagnosis and role of radiological imaging. Med J Malaysia Aug
2016;71(4):206-208
[e] Jacobs JE, Latson LA Jr, Abbara S, et al, Expert Panel on Cardiac Imaging. ACR Appropriateness Criteria® acute chest pain -- suspected aortic dissection. American College of Radiology 2014.
https://acsearch.acr.org/docs/69402/Narrative/. Accessed 5th May 2019.

DR CHOW MIN YEE

Email : minyeechow91@gmail.com