Aortic Dissection - The Great Masquerader
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1 Aortic Dissection - The Great Masquerader James Yeh MD, PhD Locum Consultant Cardiologist Cardiology & Aortic Centre, Royal Brompton Hospital Imperial College London, UK
2 Acknowledgments Prof Christoph Nienaber, Consultant Cardiologist, Royal Brompton Hospital & Imperial College London, UK Dr Mike Rubens, Consultant Radiologist, Royal Brompton Hospital, UK Mr Niteen Limbachia, WL Gore and Associates (UK) Ltd
3 Disclosure of Interest I do not have any potential conflict of interest
4 Medical History 75 male Sudden onset severe central chest pain, whilst playing base guitar in a gig. Carried on playing for 40min to finish the show. Drove home. Next morning, attended Emergency Department (ED). Past medical history Systemic hypertension Atrial fibrillation Stroke 4yr ago (mild residual weakness) Ex-smoker Crt 117umol/L, est GFR 54 ml/min Renal carcinoma R nephrectomy 4yr ago, last f/u 6mo - well Giant cell arteritis Lumbar spine decompression Medications Bendroflumethiazide, Warfarin, Digoxin, Paracetamol, Zopiclone
5 Chest X-ray `...rule out infection or widened mediastinum ED with chest pain 6 months previous (unfolded aorta noted as early as 2yr ago) Diagnosis: musculoskeletal chest pain discharged home
6 Progress Intermittent chest pain for 2 weeks Family doctor (week 2) Left upper quadrant/epigastric discomfort 10 Kg weight loss over 6 months (was on diet to loose weight) Hb 128, MCV 96.9, ferritin 745, ESR 77, CRP 29 Gastrointestinal disease, tumour recurrence (prev renal cancer)? Gastroenterology review (week 4) Gastrointestinal disease, tumour recurrence? gastroscopy + CT chest-abdo-pelvis, to be performed within 2 weeks Continued to travel to play music
7 Elective CT Scan (week 6) (looking for tumour recurrence) Type B aortic dissection Recalled from home to ED Pain free, HR 70 AF, BP 130/70 added Bisoprolol + ACEI referral aortic centre Complicated type B dissection ( risk of aortic rupture) Dissected aorta max diameter 6.1cm (ie >4cm) Partial thrombosis of false lumen Intermittent pain despite reasonable BP agreed for TEVAR Coronary angio (TEVAR workup): no flow limiting disease
8 TEVAR Procedure
9 Serial CT Aortogram Pre-TEVAR Post-TEVAR Day 3 Post-TEVAR 5 months
10 Aortic Dissection Disorders presenting with acute chest/back pain (or both) seen in ED Uncommon (5-30/million/year) 1-3 Complications develop rapidly poor outcome Per 1000 Death due to aortic Acute rupture, coronary visceral syndrome ischaemia, or tamponade 253 (Type A) Swift diagnosis Neuro-radicular & appropriate treatment = important 170 Pulmonary diseases 157 Hard to diagnose, Arrythmia need high index of suspicion 65 38% missed diagnosis; Heart failure 28% first diagnosed post mortem 50 4 Broad clinical presentation Hyperventilation (dissection may occur anywhere 33 in the aorta) Mimick more common Hypertensive disorders crisis (eg acute coronary 22 syndrome, upper GI disorder, musculoskeletal Chest wall syndrome pain) 18 Classical symptoms/signs Gastrointestinal often disorders absent 6 12 Pulmonary embolism 4 Aortic dissection 3 Pericarditis 1 No definitive diagnosis 6 Other 61 Adapted from von Kodolitsch Y et al, Roberts CS et al, Ann Surg Bickerstaff LK et al, Surgery American Heart Association Spittell PC et al, Mayo Clin Proc von Kodolitsch Y et al, Arch Intern Med Hagan PG et al, JAMA 2000.
11 Aortic Dissection: symptoms & signs Hagan PG et al, JAMA 2000.
12 Aortic Dissection: CxR, ECG, Imaging Hagan PG et al, JAMA 2000.
13 Conclusion 1. Aortic dissection may mimick more common conditions, eg, acute coronary syndrome, gastrointestinal disease, musculoskeletal pain 2. Presented 75 y/o male, acute severe pain, history of hypertension (a typical patient for aortic dissection) Diagnosis missed on 3 consultations. Contributing factors: - absence of acute changes on chest X-ray - symptoms/signs suggestive of other diagnosis - past history of tumour Subsequent CT (looking for tumour recurrence) revealed a complicated type B aortic dissection TEVAR 3. Swift diagnosis of aortic dissection requires a high index of suspicion and judicious use of appropriate imaging (eg CT) early 4. Early transfer to an aortic centre for expert management is recommended for optimal outcome
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Heart Failure in 2012 with reference to NICE Guidance Dr Maurice Pye Consultant Cardiologist York District Hospital
Heart Failure in 2012 with reference to NICE Guidance 2010 Dr Maurice Pye Consultant Cardiologist York District Hospital A little over elaborate,do not include ECG or CXR If clinical suspicion is high
TEVAR for Chronic dissections: indications for TEVAR, long term results
TEVAR for Chronic dissections: indications for TEVAR, long term results J Sobocinski, R Azzaoui, B Maurel, R Spear, T Martin-Gonzalez, A Hertault, S Haulon Centre de l Aorte, Chirurgie vasculaire, Hôpital