Had this patient come in whilst on nights.
82 y/o female presented with chest pain.
Previously had CABG >15 years ago following presentation with “unstable angina”. which resolved her angina, nil since them.
Sudden onset chest and back pain and maybe between shoulders. not really a tearing quality but different to her pre CABG angina. pain wasn’t severe but enough to get her to come in. Felt her normal self otherwise.
Not on any medications.
Tachycardia 105. BP 108/64. (bilaterally) Normal ECG sinus.
She looked pretty good TBH. sore but not “sick, sick”
Given GTN with no real change in pain. but settled with a push of morphine.
Istat troponin was negative.
Off for a CXR.
Was willing to say the mediastinum looked wide and the radiologist agreed that the aortic contour looked a bit funny. We discussed presentation and decided that CT was indicated. I pushed for the scan as my gestalt was telling me there was something unusual about this patient.
Obviously there’s dissection from “top to bottom” as a colleague described it.
Formal report came back as extensive type A dissection extending from aortic root to abdominal aorta. There is no adjacent soft tissue reaction and no high density material on the unenhanced scan. These findings strongly suggest this is a chronic dissection.The false lumen is thrombosed in several locations and patent in others Major arch branches are patent.
Summary: extensive chronic aortic dissection with aneurysmal dilatation.
So my patient was now pain free, with an “old” dissection and lowish BP. Her tachycardia had settled after the CT. With discretion being the better part of valor I admitted her to the ward overnight. Repeat troponin in the morning was negative. She also had a D-Dimer added (no one confessed to this) which was negative. Discharged home.
I saw this patient recently in GP clinic and her BP remains low, no further episodes of pain.
This was my first experience of when aortic dissection isn’t “aortic dissection” Anyone else had a similar case?
Great discussion of Aortic dissection from LITFL: http://lifeinthefastlane.com/2010/09/die-like-a-king/