THE GREAT MASQUERADERHERE
KH Ng1, WC Tan2
1 Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
Aortic dissection is a rare but the most catastrophic clinical condition that involves the aorta. It typically presents with acute tearing type of chest, back or abdominal pain. However, 6% of them come silently without pain.
A 58 years old man with no known medical illness presented to our emergency department with the main complaint of 3 days worsening shortness of breath, orthopnea, paroxysmal nocturnal dyspnea and reduced effort tolerance. Otherwise, there were no history of chest pain and fever. On examination, he is tachypneic with increased JVP, bibasal crepitations of lungs and systolic murmur at mitral area of heart. Otherwise, the vital signs are stable and there is no radio-radial delay. ECG shows sinus tachycardia with poor R wave progression. Chest x-ray shows cardiomegaly with signs of overload. Blood investigations including troponin T are not remarkable. Bedside ultrasound shows dilated ascending aorta about 5cm, intimal flap from ascending aorta extending to abdominal aorta. Diagnosis of dissecting aortic aneurysm was made. Emergency CTA of thorax and abdomen show Standford A aortic dissection with intimal flap from aortic root to proximal abdominal aorta at the level of renal arteries. Patient was referred to cardiothoracic center for further management.
Discussion and conclusion
Aortic dissection is a catastrophic event which is associated with serious morbidity and mortality. However, the diagnosis in ED is challenging and require a high index of suspicions. Statistic shown that less than 10% of patients presented with atypical symptoms, and 6% of patients even presented without any pain. What explained the absence of pain in cases of aortic dissection is because the adventitia is the only innervated layer of the vessel wall and thus pain would not be elicited if it is preserved.
Bedside ultrasound is an easily available modality for diagnosing aortic dissection. As in this case, with the clinical sign and symptoms, patient was initially treated as decompensated heart failure. However, diagnosis was revised based on point of care ultrasound.