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Abstract

Introduction:

Aortic dissection represents a critical emergency characterized by the cleavage of aortic wall layers, creating a deceptive false lumen. Associated with high mortality rates, prompt diagnosis and intervention are needed to ensure survival.

Case:

A 63-year-old male with no significant medical history presented to the emergency with two days of worsening mid-sternal chest pain. Upon presentation, he was hemodynamically stable. Blood pressure was 130/85 mm Hg (similar in both arms), heart rate 90 bpm, and saturating 98 % on room air. Physical examination did not reveal any new murmurs. EKG showed normal sinus rhythm, no ischemic changes, and a negative troponin50), but given low clinical suspicion for a pulmonary embolism, a CT angiography (CTA) was not pursued, especially since Wells Score was 3. The patient did meet one criterion (chest pain) for The Aortic Dissection Detection Risk Score, but unfortunately, neither a D-Dimer nor CTA was performed due to low clinical suspicion. Chest pain improved after Aspirin, sublingual Nitroglycerin, and Morphine. Troponin was negative x 2. A transthoracic echocardiogram, conducted after a delay of ten hours, disclosed a dilated aortic root measuring 4.7 cm and a 5 cm dilated ascending aorta. Additionally, a linear echo-density exhibiting flow, corroborated by color Doppler, raised suspicion of aortic dissection originating close to the right coronary cusp. Cardiothoracic surgery was immediately consulted, and a CTA was ordered. Regrettably, twenty minutes later, the patient became unresponsive with PEA cardiac arrest, and CPR was initiated. After 18 minutes of CPR, there was no return of spontaneous circulation, and the patient was pronounced deceased.

Discussion:

Our case underscores the deceptive nature of aortic dissection, which can present with benign physical examination, labs, and radiographic findings. In cases of uncertainty, prompt imaging with transthoracic/ transesophageal echocardiography or CTA should be performed as early detection and treatment can significantly improve prognosis.

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