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A 43-Year-Old Man Presenting With Severe Chest PainA 43-Year-Old Man Presents With Severe Chest Pain FREE TO VIEW

Pablo Blanco, MD
Author and Funding Information

From the Intensive Care Unit, Hospital Dr Emilio Ferreyra, Necochea, Argentina.

CORRESPONDENCE TO: Pablo Blanco, MD, Intensive Care Unit, Hospital Dr Emilio Ferreyra, 4801, 59 St, Necochea 7630, Argentina; e-mail: ohtusabes@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(3):e76-e79. doi:10.1378/chest.14-2623
Text Size: A A A
Published online

A 43-year-old man was brought to the ED with chest pain that had evolved for the previous 2 hours. His personal medical history revealed poorly controlled arterial hypertension and active smoking. Family history highlights included his father’s sudden death at age 40 years.

On presentation, the patient’s vital signs were a regular heart rate at 80/min, BP of 220/120 mm Hg, respiratory rate of 24/min, and temperature of 36°C. Pulse oximetry saturation was 95% on room air. The physical examination revealed a lucid but uncomfortable and poorly cooperative patient. He stated that the pain originated in the precordium but later radiated to the interscapular area. Pain was severe from the beginning; it was not accompanied by nausea, vomiting, or diaphoresis and did not reproduce with palpation. He looked pale but well perfused; a high-intensity second sound was heard on cardiac auscultation, and no murmurs were noted. Central and peripheral pulses were present and symmetric. Respiratory examination indicated clear lung fields. ECG showed regular sinus rhythm at 80/min. No Q waves, ST-segment deviation, or negative T waves were noted. High-voltage QRS complexes compatible with left ventricle (LV) hypertrophy were seen. A medical ICU consultation was called. After initial history, physical examination, and ECG review, bedside ultrasound (transthoracic echocardiogram [TTE]) was performed to evaluate the etiology of chest pain (Video 1).

Video 1

Running Time: 1:39

Based on Video 1, the ECG, and the patient’s clinical presentation, what is the most likely diagnosis?
Answer: Acute aortic dissection

Video 2

The images in Video 2 show the suprasternal notch of the ascending aorta, aortic arch, and proximal descending aorta to help rule out a proximal dissection. This patient presented with chest pain, the origin of which remained uncertain after clinical and ECG findings. Due to the presence of symptoms and signs of organ damage and extremely elevated BP, the diagnosis of hypertensive emergency was first considered. Possible diagnosis was acute myocardial ischemia or infarction (AMI), although ECG did not show a myocardial ischemic pattern. However, a normal ECG may be present in up to one-third of patients with coronary involvement.1 Another diagnostic possibility was acute aortic dissection (AAD). Nevertheless, about 20% of patients with type A AAD have ECG evidence of acute ischemia or AMI1 and/or wall motion abnormalities (WMAs) detected by TTE (particularly LV inferior hypokinesia). These figures highlight the need to rule out AAD, even in classic cases of AMI. Two other potentially fatal diagnoses could be pulmonary embolism and esophageal rupture. However, these two diagnoses are less likely due to the elevated BP, normal right ventricle [RV] size and function, no hypoxemia, and no evidence of pleural effusion on ultrasound, respectively.

Video 3

Running Time: 8:04

As discussed in Video 3, a TTE, subcostal, four-chamber view (Video 1, Clip 1), although limited to some segments of basal-midventricular regions, suggested normal LV and RV size and systolic function. In the subcostal longitudinal view (Video 1, Clips 2, 3), an enlarged aorta was noted (2.65 cm [normal ≤ 2 cm]) with an intimal flap seen inside, compatible with aortic dissection. A parasternal long-axis view (Video 1, Clip 4) showed normal LV systolic function and no WMAs. The aortic root was dilated (4.3 cm [normal ≤ 3.5 cm]) with no intimal flap seen inside, and a trace aortic regurgitation (AR) jet was revealed on color Doppler imaging. A moderate to severe acute AR is present in nearly one-half of patients with type A aortic dissection. Accordingly, the absence of significant AR does not rule out the diagnosis of this type of dissection. Apical four- and two-chamber views (Video 1, Clip 5) showed normal RV and LV systolic function with no WMAs. In a modified apical two-chamber view (Video 1, Clip 6), the medium-distal portion of the descending thoracic aorta was seen behind the left atrium, with an intimal flap inside and two lumina noted. No pleural or pericardial effusion was noted. Pericardial effusion could be a complication of type A dissections and pleural effusion of type B dissections, both indicating aortic rupture into these cavities. Because the cranial portion of ascending aorta, aortic arch, and proximal thoracic descending aorta are not seen with the conventional TTE views, the next logical step would be to perform a suprasternal view to determine if a type A (involving the ascending aorta) or a type B dissection (not involving the ascending aorta) is present.

Video 2 shows the distal portion of the ascending aorta and aortic arch with no intimal flap inside. Color Doppler ultrasound revealed antegrade flow (red, toward the transducer) in the ascending aorta. Blue flow (away from the transducer) was noted corresponding to the venous brachiocephalic trunk flow. This flow should not be misinterpreted as a false lumen. A normal posterior aortic wall (arrow) must not be misinterpreted as an intimal flap. The aortic arch was normal in diameter (2.7 cm [normal ≤ 3 cm]) with no intimal flap inside. The proximal descending aorta was enlarged (3.17 cm [normal ≤ 2.5 cm]). No double lumen was noted, although echogenic material was seen in the medial side (arrows with question sign), suggestive of a hematoma formation.

Because the ascending aorta was not compromised, Stanford type B classification of a dissecting aortic aneurysm was presumably diagnosed. Thoracic and abdominal CT scans corroborated these findings (Figs 1-3).

Figure Jump LinkFigure 1 –  Chest CT scan in transverse section demonstrating a false lumen (arrow) and a true lumen (black star) within the proximal descending thoracic aorta. The ascending aorta is not involved (arrowhead).Grahic Jump Location
Figure Jump LinkFigure 2 –  Chest CT scan in transverse section demonstrating a false lumen (arrow) and a true lumen (black star) within the medium-distal portion of the descending thoracic aorta, behind the LA. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.Grahic Jump Location
Figure Jump LinkFigure 3 –  Abdominal CT scan in transverse section demonstrating an intimal flap and a true lumen (arrow) and a false lumen (black star) within the proximal abdominal aorta (arrow).Grahic Jump Location

AAD is a challenging clinical emergency. The incidence of AAD has been estimated to range from 2.9 to 3.5 occurrences per 100,000 person-years, whereas the incidence of AMI is several orders of magnitude greater (> 200 cases per 100,000 person-years).2

Differentiating aortic dissection from myocardial ischemia is a common clinical dilemma, and because the therapeutic strategy is very dissimilar, a rapid and accurate diagnosis is essential.3 In fact, the management with antiplatelet and antithrombin agents may cause harm to the patient with AAD.2

In the International Registry of Acute Aortic Dissections, the mean age of patients with AAD was 63.1 years, and type A dissection was present in 62% of patients. Patients with type B dissection were older on average.3 However, AAD may occur in younger patients.2

Since dissection is a dynamic process that may occur anywhere within the aorta, the clinical spectrum of presentation is broad. Symptoms may mimic more common disorders, such as myocardial ischemia or stroke, and physical findings may be absent or suggestive of a diverse range of other conditions. Therefore, dissection is often difficult to diagnose, and a high clinical index of suspicion is mandatory.3

Approximately 40% of chest radiographs in patients with AAD lack a widened mediastinum, and as many as 16% are normal; therefore, the absence of radiographic abnormalities does not exclude the diagnosis of AAD.2

In this manner, point-of-care TTE performed by emergency or critical care physicians is recommended for all patients with suspected aortic dissection and should be considered for all patients with chest or abdominal pain of uncertain etiology. In addition to evaluating alternative diagnoses, an intimal flap at either the aortic root or descending aorta may be distinguished by TTE and is diagnostic. TTE also reliably identifies complications of aortic dissection, such as a pericardial effusion, pleural effusion, and AR.4 Because some parts of the thoracic aorta are not entirely visualized with TTE, other diagnostic imaging modalities are usually required to corroborate the diagnosis and the extension of the dissection.5

The patient was admitted to ICU and medically treated. His BP was invasively monitored and treated with IV β-blockers and sodium nitroprusside. His evolution was uneventful, and he was discharged from the hospital on day 20.

This case demonstrates the great value of ultrasound for study of patients with undifferentiated chest pain. It highlights the practice of evaluating the aorta even in patients with ECG findings or WMAs suggestive of myocardial ischemia.

  • 1. Bedside TTE is a helpful method of evaluation of patients with undifferentiated chest pain, allowing intensivists to rapidly and accurately rule in or out a potentially fatal diagnosis.

  • 2. Inspection of the abdominal aorta in the subcostal view should be standard practice when aortic pathology is suspected.

  • 3. Typical findings of a proximal AAD, such as dilation of the aortic root, a false lumen, and AR, should be sought with transthoracic ultrasound. If possible, a suprasternal notch view may allow visualization of the distal ascending aorta, aortic arch, and the proximal descending thoracic aorta.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the author to ensure that the Journal policies on patient consent to report information were met. The author would like to thank Julieta Vigna, English-Spanish translator, for language guidance.

Additional information: To analyze this case with the videos, see the online version of this article.

Erbel R, Alfonso F, Boileau C, et al; Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22(18):1642-1681. [CrossRef] [PubMed]
 
Hiratzka LF, Bakris GL, Beckman JA, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121(13):e266-e369. [CrossRef] [PubMed]
 
Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903. [CrossRef] [PubMed]
 
Strayer RJ, Shearer PL, Hermann LK. Screening, evaluation, and early management of acute aortic dissection in the ED. Curr Cardiol Rev. 2012;8(2):152-157. [CrossRef] [PubMed]
 
Meredith EL, Masani ND. Echocardiography in the emergency assessment of acute aortic syndromes. Eur J Echocardiogr. 2009;10(1):i31-i39. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Chest CT scan in transverse section demonstrating a false lumen (arrow) and a true lumen (black star) within the proximal descending thoracic aorta. The ascending aorta is not involved (arrowhead).Grahic Jump Location
Figure Jump LinkFigure 2 –  Chest CT scan in transverse section demonstrating a false lumen (arrow) and a true lumen (black star) within the medium-distal portion of the descending thoracic aorta, behind the LA. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.Grahic Jump Location
Figure Jump LinkFigure 3 –  Abdominal CT scan in transverse section demonstrating an intimal flap and a true lumen (arrow) and a false lumen (black star) within the proximal abdominal aorta (arrow).Grahic Jump Location

Tables

Video 1

Running Time: 1:39

Video 2

Video 3

Running Time: 8:04

References

Erbel R, Alfonso F, Boileau C, et al; Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22(18):1642-1681. [CrossRef] [PubMed]
 
Hiratzka LF, Bakris GL, Beckman JA, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121(13):e266-e369. [CrossRef] [PubMed]
 
Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903. [CrossRef] [PubMed]
 
Strayer RJ, Shearer PL, Hermann LK. Screening, evaluation, and early management of acute aortic dissection in the ED. Curr Cardiol Rev. 2012;8(2):152-157. [CrossRef] [PubMed]
 
Meredith EL, Masani ND. Echocardiography in the emergency assessment of acute aortic syndromes. Eur J Echocardiogr. 2009;10(1):i31-i39. [CrossRef] [PubMed]
 
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