36 yo M, no pmhx, appears morbidly obese, no hx of HTN,but has been told once he has borderline HTN, takes no meds. Presents by car with his father. Patient states he had sudden onset left upper chest pain that radiated to his neck with mild sob and mild lightheadedness that started when he was walking up stairs. He states the sob and lightheadedness have resolved and now the chest pain is mild. It did not radiate to his back. Nonexertional, nonpleuritic. No hx of DVT or PE, no leg swelling or pain. Denies abd pain. Denies diaphoresis or nausea. Pt is a smoker. Denies drug use, admits social alcohol use. Denies Fhx of early heart disease or suddent death.

PE is unremarkable

Vitals: Hr 110, BP 122/84, RR 20, RA P02 97%, Temp 36.3

EKG: NSR no acute st or t wave changes HR 110

Inital A/P:

Well appearing morbidly obese patient with exertional onset left chest pain radiating to left neck, no radiation to back. Denies medical hx and follows w a primary doctor. Normal PE, no risk factors for PE. No fmhx of CAD. Non ischemic ekg and pain is currently mild. He did state his pain was moderate to severe at onset.

Planned DDimer, trop x2, CXR, labs, and entering the patient into CPEP protocol with planned AM stress cardiac echo

Patient initially refused admission but was talked into staying for the protocol. wow

Results:

Tropx2 negative

DDimer negative

2 view CXR negative

CBC CMP normal

repeat ekg - non ischemic tachycardia resolved

At 7am near the end of signout I was called by the nurse as the patient just vomitted and BP was 100/55, HR was still 70s.

I reevaluated the patient and he appeared well and stated his pain returned and was still mild left CP radiating to his neck. No other complaints besides nausea.

At this point I figured he couldnt do the stress test and changed him to an admission. I decided to reevaluate if there was anything I was missing.

Due to my past mental trauma from seeing 7 total patients younger than 45yo with aortic dissection in 7 years of residency/practice and 1 of those patients dying from their dissection.....I decided if I was to get any sleep I would need to get a CTA chest abd pelvis w and wo contrast prior to admission to tele. The tipping point in my mind was why was this guy borderline hypotensive if he is in pain and morbidly obese. Even with only moderate pain without alot of the classic symptoms of dissection. He even had bilateral BPs done by accident which were not marked abnormal. Also normal 2V chest and normal DDimer. All prior 7 dissections in young people that I had seen had elevated DDimers. It is NOT a sensitive test but with very low suspicion...sometimes to me it is somewhat reaasuring....THere is much debate about it's utility.

830am CTA results:

Large aneursymal dilatation of the proximal aorta and aortic valve. Largest aortic diameter is 6cm. Cannot rule out dissection within the aneursym. Moderate size pericardial effusion vs pericardial hematoma.

Cardiothoracic surgeon immediately paged. Cards came to the bedside.

11am Bedside ECHO results:

1pm in the OR

TEE confirms a dissection just above the aortic valve within the aneurysm. Moderate aortic regurgitation. Moderate to severe pericardial effusion.

Cocaine negative on UTox

In the OR:

Patient had cardiac bypass/open chest sugery with replacement of ascending aorta w graft and his aortic valve was repaired but not replaced.

Post op day #1 the patient was extubated and stated he felt fine except for some incisional pain.

WOW...dodged a bullet

Almost gave this guy a stress test. He didnt even want to stay for that. Thankfully he vomitted and had borderline hypotension and thankfully I have a history w dissection that has made me a little more cautious....or I would have missed this. Could've been my second death from a missed dissection...probably on the tredmill in the stress lab. The prior death of a patient I had from dissection was a 33 yo M with a similar presentation and workup as this patient. I discharged him and he came back on my same shift and died within 30 of arrival.

Normal BP on arrival. Normal bilateral BPs. Normal 2V CXR. negative trops and ddimers.....recipe for disaster.

Thanks to the resident and the next attending for fully taking over this guy at 1030 am and making sure he got the ECHO and the OR.

Take homes:

- Morbid Obesity is a risk for other comorbidities (undiagnosed HTN) and dissection. None of my young dissections appeared marfanoid but almost all were obese with probable undiagnosed or poorly treated HTN

Kyobu Geka.

2013 Jun;66(6):437-44.

[Obesity is a risk factor of young onset of acute aortic dissection and postoperative hypoxemia].

[Article in Japanese]

- He was never truly hypotensive but borderline hypotension in a patient you would think would be hypertensive with chest pain should raise some eyebrows

- DDimer has been argued by some as a screening test for dissection but it's not sensitive enough. This case illustrates that. I feel that you could miss fewer dissections by using it w risk stratification, normal pulses in all four, normal 2V cxr, normal bilateral BPs etc, but if you have clinical suspicion...you have to scan

- Consider doing some documentation with chest pain patients that would make your chart more defensible in case you miss AD. They are easy to miss and I have been there - things you could add would be equal pulses in all 4 ext, equal bilat BPs, normal CXR, and reasoning that you think the probability of dissection is so low that CTA is not indicated.

- Some experts on aortic dissection argue that its presentation can be so nonspecific that the standard of care is to not make the diagnosis.

Below is a CTA image showing the proximal aortic dilation and some evidence of the pericardial effusion