Chest Pain

Hx: It’s the start of your shift and EMS brings a “chest pain” patient to the ED. They report a 62 yo female with onset of chest pain while on a treadmill. She called 911, EMS arrived and administered aspirin and held nitro because her pain was improving and her vitals were normal. IV placed in transport and no other interventions.
You go to interview the patient and note she is ill appearing. She notes she was on a treadmill when she developed severe mid sternal chest pressure with radiation to the back, and then fell as her right leg gave out. The chest pain  improved quickly and is now gone. However, she does have severe low back pain radiating into the right leg and can’t find a position of comfort.

Past medical history: none.

Soc hx: No smoking; occasional wine, no drugs. She is fit and exercises regularly.

Exam: 
• General- she appears in pain, and pale. Looks younger than her age.
• Vitals- HR 95, BP 80/60, Temp 98, O2 sat 100% RA
• Cardiovascular- RRR, no murmurs, normal pulses x 4 extremities, no edema
• Lungs- CTA B
• Abdomen- soft, NT, ND, no masses
• Extremities- warm, sensation normal, no significant change in pain with movement right hip or knee.
• Neuro- normal

Additional Hx: The paramedics are questioned about blood pressure and state  her BP and pulse were normal in route to the hospital. No hypotension.

Additional Vitals: Blood pressure is measured in both arms and noted as:  right arm 120/85 , left arm 80/60

Dx: A CT angiogram confirms the suspicion and visualizes a type A dissection involving the entire aorta starting just proximal to the arch. It extends into the left subclavian and right femoral artery as well. Images below demonstrate the extent of dissection.

Dissection seen along entire length of aorta.

Dissection flap seen in the ascending and descending aorta.

Distal aorta dissection flap is seen with near total occlusion of right femoral artery (small amount of contrast in vessel).

Discussion: This case highlights the physical exam and history findings that point to aortic dissection. The patients transient severe chest pain radiating to the back, and persistent pain in the lower back radiating to the right leg should increase concern for dissection. Additionally, the blood pressure discrepancy in the arms confirms the diagnosis. Although presentation for dissection is typically hypertensive in type B (descending aorta), up to 25% of type A presentations can present with acute hypotension without a history pre-existing hypertension, drug use, or connective tissue disorder. Treatment of type A dissection is surgical with a mortality greater than 50% within 3 days if left untreated.

Outcome: The patient was emergently taken to the operating room. The dissection reached the aortic root as surgeons were placing her on bypass. She underwent ascending aortic replacement and valve repair. She also required vascular stenting of her femoral artery and survived with good neurological outcome.

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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