A rare presentation of aortic dissection

Lauren Skerritt,Naitik Patel

doi:10.5348/101064z01ls2019cr

Abstract

Introduction: Aortic dissection (AD) is a rare, life-threatening event that presents as acute chest pain, radiating to the back, often in the setting of hypertension. Aortic dissection is the most common fatal aortic pathology, yet the initial diagnosis is often missed. Additionally, a minority of patients present with either no symptoms or neurologic symptoms. This patient exhibited atypical presentation of AD and the purpose of this report is to raise awareness. Case Report: A 79-year-old woman with past medical history of hypothyroidism, osteoporosis, and chronic obstructive pulmonary disease (COPD) presented with bradycardia, acute chest pain, and generalized weakness. She was afebrile, her blood pressure was 100/54 mmHg, heart rate was normal sinus rhythm (NSR) at a rate of 81bpm, respiratory rate 17 breaths per minute. Patient was AO × 3. Physical exam was unremarkable, except for trace pitting edema in bilateral lower extremities. Electrocardiogram (ECG) showed normal sinus rhythm at a rate of 86 with low voltage. Troponin I level was negative × 3. Chest X-ray (CXR) showed no acute cardiopulmonary findings. Transthoracic and carotid echocardiogram revealed a dilated aortic root and dissection of the thoracic aorta. A computed tomography (CT) angiogram of chest, abdomen, and pelvis revealed a Type A AD of the thoracic and abdominal aorta, involving the common carotid arteries, left common iliac, and left external iliac arteries. Conclusion: Aortic dissection is a life-threatening emergency that requires early detection and treatment to decrease patient morbidity and mortality. However, it is difficult to diagnose as it can present with atypical findings and is frequently mistaken for other etiologies that cause chest pain such as acute coronary syndrome.

Highlights

Aortic dissection is a rare but life-threatening event that classically presents as acute chest pain, radiating to the back, often in the setting of hypertension
A minority of patients present with either no symptoms or neurologic symptoms such as full body weakness, making dissection even more difficult to successfully diagnose [5, 6]. This patient exhibited an atypical presentation of aortic dissection, initially with bradycardia, temporary generalized weakness, and chest pain
Type B Aortic dissection (AD) is best managed with medical therapy rather than surgical intervention if the dissection is stable, the patient’s hypertension does not persist, and if there is no major aortic branch occlusion leading to organ ischemia

Summary

INTRODUCTION

Aortic dissection is a rare but life-threatening event that classically presents as acute chest pain, radiating to the back, often in the setting of hypertension. This patient exhibited an atypical presentation of aortic dissection, initially with bradycardia, temporary generalized weakness, and chest pain. A 79-year-old woman with a past medical history significant for hypothyroidism, osteoporosis, and COPD presented initially to Hahnemann University Hospital by Emergency Medical Services (EMS) after being found to be bradycardic with acute chest pain and generalized weakness. In the Emergency Department, she reported improvement to the chest pain, but reported chills and a headache; remaining review of systems was negative She was afebrile, blood pressure 100/54 mmHg, heart rate was normal sinus rhythm at a rate of 81 bpm, respiratory rate 17 breaths per minute. Given the severity and extent of the aortic dissection, CT surgery was contacted, and the patient was emergently transferred to Hospital of the University of Pennsylvania where she underwent surgery

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