Ticking Time-Bomb: Diagnostic Strategy of Aortic Dissection

Abstract

Introduction

Aortic Dissection is a frequently misdiagnosed life-threatening condition that requires a high index of suspicion in clinching the diagnosis due to its vagueness and variety in clinical presentation. Textbooks describe chest x-ray findings suggestive of an aortic dissection, but the sensitivity is lower in comparison to the very instrumental bedside ECHO.

Case report

A 61 year old Chinese gentleman with no known medical illness had presented to the Emergency Department complaining of epigastric and chest discomfort that is difficult to describe. On further probing, he describes the pain to be ripping in nature, with a pain score of 8/10, non-radiating, not associated with autonomic symptoms and volunteered a history of right lower limb cramps. Patient had an initial misleading systolic BP of 144/103 and HR of 76 and appeared comfortable, and was hence triaged to yellow zone. On further assessment, he was perspiring with coolish peripheries, but normal capillary return and good pulse volume. There was no radioradial or radiofemoral delay and no murmur. ECG showed sinus arrhythmia while erect chest x ray showed no obvious mediastinal widening with grossly normal aortopulmonary window. A bedside ECHO, however, revealed a dilated aortic root at 4.2cm and a CT Angiography was requested on that grounds, unveiling Stanford A Aortic Dissection. Patient was referred to the surgical team and transferred to a cardiothoracic facility for urgent surgery.

Discussion & Conclusion

This case illustrates the sensitivity of ECHO as a point of care diagnostic tool in suspected aortic dissection, overruling traditional chest x ray findings. Recognition of not relying on non-specific chest x ray findings in a patient whose clinical history maybe suspicious of an aortic dissection is critical in the decision making of referring to the surgical department and as a ground of requesting for the gold standard CT Angiography.