A patient with chest pain due to acute aortic dissection

chest pain

A 74-years-old lady presented with a history of collapse preceded by chest discomfort. On examination, she was haemodynamically stable. She complained of vague chest discomfort, dizziness and neck pain. Repeated ECGs were normal except for sinus bradycardia, cardiac enzymes normal, Troponin-T negative, X-ray cervical spine-spondylosis and CT brain scan showed degeneration of cerebral cortex. A provisional diagnosis of TIA due to cervical spondylosis was made. She was discharged on request in next 72 hours of admission. She was readmitted with similar complaints of dizziness, vague chest discomfort, abdominal pain and diarrhoea and before admission, she had a momentary collapse. The cardiac evaluation did not reveal anything specific except for echo which suggested aneurysm of ascending aorta. X-ray chest this time showed widened mediastinum and a positive calcium sign (the distance between the calcification of aortic notch and the outer border of aortic shadow >1 cm). An immediate CT scan of the thorax was done which confirmed the presence of aortic dissection from ascending aorta right up to the abdominal aorta. The surgical opinion was taken and in view of her age and the nature of the disease, the high risk of surgical intervention was explained to the relatives and conservative line of management was pursued.

She was treated with nitroglycerine infusion to keep her BP around 120/80 mmHg. Unfortunately, within next 24 hours, she developed sudden chest pain and had a cardiac arrest possibly due to a proximal extension of the dissection and could not be resuscitated. The cause of her death was due to dissection of ascending and descending aorta.

DIAGNOSISAcute aortic dissection.

This is a fairly uncommon condition in the Indian setting. In last 13 years in my hospital practice, I have come across only two cases of diagnosed aortic dissection.However, the clinician should be aware of this situation before thrombolysing for suspected myocardial infarction. Points in favour of acute aortic dissection are-

  • History of hypertension
  •  Elderly
  •  No definite ECG evidence of MI (although there may be ECG evidence of MI if coronary ostia are involved by the flap).
  • The initial pain is very severe and so intense that the patient collapses. It is sharp and stabbing in nature which finally degenerates into a constant dull ache and can be radiated to the back.
  • There may be pulse deficit because of the pressure from the false lumen of the aortic conduit.
  • Differential BP in two arms.
  • There may be a neuro deficit if the dissection involves the carotid arteries.
  •  Abdominal pain- if the involvement of mesenteric arteries (as possible in this case.
  • paraplegia- due to the involvement of the spinal arteries.
  • Presence of aortic regurgitation.
  • On X-ray- widened mediastinum, positive calcium sign.
  •  Echo showing effusion or aortic flap.
Other diagnostic tests are

1.  Aortogram (advantage: coronary anatomy can be demonstrated)

2.  Contrast CT (as used in this case)

3.  Contrast MRI (better than CT)

4.  Trans-oesophageal echo

MANAGEMENT:

Dissection is classified into:

Stanford Type A – All dissection involving the ascending aorta (managed

surgically).

Stanford Type B – All dissections not involving the ascending aorta (managed

medically).

[De Bakey-      Type I ascending aorta may extend beyond it.

Type II – continued to descend aorta

Type III – originates in the descending aorta and extends distally.]

Left untreated acute dissection has a high mortality. Initial management is medical, however. This involves pain relief, control of  cardiac failure and strict control of BP and the drugs commonly used are :

1)   Nitroglycerine Infusion

2)   Nitroprusside Infusion

3)   Labetalol infusion (not generally available in India)

4)   Beta-blocker like esmolol infusion.

5)   Sublingual nifedipine may also be used if beta blockers are contraindicated.

However, the definitive treatment for acute dissection is surgical repair particularly dissection involving the proximal aorta. Surgical intervention is also indicated in distal dissection if there is a compromise of the vital organs and when it occurs in patients with Marfan’s syndrome.

Medical management is preferred in patients with uncomplicated distal dissection and stable chronic dissection (uncomplicated dissection presenting 2 weeks or later after the onset).

This patient had Type-A aortic dissection and in view of her age the extent of the dissection and high-risk surgical procedure, it was decided to take a conservative approach with control of her BP, pain relief and the maintenance of haemodynamic status at least for the initial period of time. Unfortunately, within 24 hours of the diagnosis, she had a cardiac arrest and died.

CASE: a 63 yrs old male presented with severe left-sided chest pain of two hours duration. The pain was constant in nature and increased with a cough and breathing. Recently he had a febrile episode. Examination revealed a pleuritic rub and few crepitations at the left base. X-Ray chest revealed a left basal pneumonia with pleural reaction.

DIAGNOSIS:  Pneumonia with pleuritic chest pain.

CASE: A 32 years old lady presented with the left sided chest which was continuous in nature. She was having breathlessness along with drowsiness. She was haemodynamically stable. X-Ray Chest and ECG were normal. Blood gas showed normal PaO2 and PaCO2 levels with respiratory alkalosis. Clinically there was no evidence of deep vein thrombosis.

DIAGNOSIS:  Functional chest pain with hyperventilation.

(Caveat- possibility of pulmonary embolism should always be thought of).

CASE: A 56 years old male presented with intermittent left sided chest pain of two days duration. The pain was sharp in nature and could not be localized properly. ECG, X-Ray Chest and Echo were normal. Troponin-T, CPK, CPK-MB were also normal. The patient was admitted and given treatment in the line of unstable angina. However 48 hours later he developed the classical rash of Herpes zoster in the left upper intercostals nerve segment and the diagnosis was revised as intercostal neuralgia due to Herpes zoster.

DIAGNOSIS: Neuralgic pain due to Herpes zoster.

DISCUSSION: Chest pain is one of the commonest causes of presentation in the emergency department with the myriad of causes ranging from a psychosomatic illness to life-threatening conditions like heart attack, pulmonary embolism, aortic dissection etc.

Frequently clinical examination and investigations may be elusive and a thorough history taking which is almost a forgotten art in the era of technology-oriented modern medicine may help in clinching a proper diagnosis.

Causes of chest pain :

·       Cardiac:  Myocardial Infarction, IHD, acute aortic dissection, pericarditis, aortic stenosis

·       Gastrointestinal:  Peptic ulcer, oesophageal reflux, oesophageal spasm, acute cholecystitis

·       Pulmonary:  Pneumonia, pneumothorax, pulmonary embolism, lung cancer

·       Musculoskeletal: Acute cervical disc prolapse, costochondritis, vertebral collapse due to any cause like osteoporosis etc

·       Neuropsychiatric:  Intercostal neuralgia may be functional. However, since myocardial infarction and ischaemia are common conditions presenting to the emergency department with frequently normal ECG initially history may give useful clues to make a proper diagnosis.

Symptoms favouring MI/IHD:

  • Usually retrosternal in location.
  • Usually, radiation towards the left arm, jaw and left shoulder sometimes to the right side, exertion-related, compressive type.
  • Associated nausea, vomiting and perspiration relieved by sublingual nitroglycerine.
  • Associated with sweating.
  • Males and postmenopausal women with presence of risk factors.Symptoms suggesting other causes than IHD.
  • Infra-mammary location, sharp in nature
  • Reproducible by palpation (tender spot)
  • Changes with position, cough and respiratory movement
  • Other causes which symptom-wise closely resembling angina: Oesophageal reflux- Burning,

Other causes which symptom-wise closely resembling angina:

Oesophageal reflux-

Burning, retrosternal, postprandial

[Relieved by antacids]

Oesophageal spasm-

Retrosternal, may be relieved by nitroglycerine

[Sometimes very difficult to differentiate from IHD]

Pulmonary embolism –On the side of the embolism

Pericarditis– sharp, retrosternal, may be relieved by stooping forward, may radiate towards the left shoulder

Pneumonia– pleuritic in nature, lateralized, varies with respiration

Gall Stone Peptic Ulcer– Substernal or epigastric [burning in nature]

Aortic dissection– Acute, severe, radiates towards the back with differential BP on both hands

Herpes Zoster – Sharp, lateralized, dermatomal distribution

INVESTIGATIONS IN EMERGENCY DEPARTMENT:

  • ECG
  • X-Ray Chest (PA)
  • Cardiac markers like Troponin T and Troponin I

If the clinical features and tests are inconclusive it is always preferable to admit the patient and do serial ECG and blood tests, Echocardiography, skeletal  X-Ray like cervical spine, dorsal spine, ultrasound of abdomen and if still, the diagnosis is not forthcoming, the patient should be offered to undergo conventional coronary angiography (in high-risk patients) or a CT Coronary angiogram (in low-risk patients). Once cardiac causes are excluded, one may investigate the gastrointestinal tract on the outpatient basis. Missing an appropriate cause for chest pain is a common medicolegal issue in the western country, which is also becoming a problem in India as well.

Sometimes the patients, mainly middle-aged female, present with classical chest pain with ECG changes and subsequent coronary angiogram show the normal pattern. Thallium Scan also shows positivity for ischaemia. This condition is known as Syndrome ‘X” which is thought to be either due to small vessel disease or diminished coronary reserve.Nicorandil or trimetazidine may be tried as therapeutic options.

CASE: A 26 years old lean and thin male patient attended the emergency with a recurrent history of a cough and cold. The reason of presentation was sudden onset of sharp pleuritic chest pain on the left side. Initial X-Ray Chest and ECG in the clinic did not reveal anything specific. The patient refused admission and was prescribed a course of antibiotics. The next day the patient developed shortness of breath and presented to another hospital where he was finally admitted. Repeat X-Ray and a C.T. Scan showed a moderately sized pneumothorax on the same side. He was put on a chest drain with symptomatic relief. On retrospective analysis, it was noticed that he had a small chink of pneumothorax on the very first day which was missed in the emergency department and finally the pneumothorax increased with symptoms of breathlessness which was detected easily in the subsequent chest films.The patient was subsequently diagnosed to have Marfan’s syndrome and had repeated pneumothorax on the same side which later led to surgical intervention for the pneumothorax.

DIAGNOSIS:  Pneumothorax in a patient with Marfan’s syndrome.

: KEY POINTS :

  • Chest pain is a common problem in clinical practice.
  • The cause may vary from trivial causes to life-threatening condition.
  • A proper clinical history and basic investigation will clinch the diagnosis in the majority of cases.
  • Acute aortic dissection is an uncommon cause of acute chest pain.
  • Initial diagnostic workup may be normal.
  • A high index of suspicion should be present in the patient with Marfan’s syndrome. (hypertensive and elderly patients presenting with intense chest pain and non-diagnostic ECG)
  • Clinical examination, X-ray Chest and echo can give some diagnostic clues.
  • Before discharging the patient with acute chest pain or thrombolysis for clinical suspicion of MI, dissection should be excluded.

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