A Case of Acute Aortic Dissection Presenting with Chest Pain Relieved by Sublingual Nitroglycerin
A 77-year-old Korean woman came to the outpatient clinic of the department of family medicine, Seoul National University, Seoul, Korea, presenting with chest pain that started the day before. She had a medical history of hypertension and had been on medication (losartan and aspirin) for 5 years. The day before, at about 7 PM she suddenly felt a strong chest pain of numerical rating scale (NRS) 8-10 in the substernal area. She described the character of the pain as oppressive without radiating pain. This excruciating pain lasted for about 10 minutes combined with a doomed feeling, diaphoresis, and difficulty in taking deep breaths. She also felt slight faintness with urinary incontinence. She visited a local clinic the next morning and chest pain was relieved to NRS 3-4 after 3 tablets of sublingual nitroglycerin. When she came to our outpatient clinic, she presented with moderate chest pain of 3/4 on the NRS. She looked acutely ill, and nothing specific was detected in her heart and lung sounds. Under assessment of ACS she was immediately referred to the emergency department. Initial vital signs at the emergency room were stable: blood pressure 108/75 mm Hg, pulse rate 82/min, respiration rate 20/min, body temperature 36.6℃, saturation 99%. Electrocardiogram (EKG) was immediately taken which showed normal sinus rhythm with nonspecific ST deviation. Laboratory findings were as follows: creatine kinase (CK) 129 IU/L, CK-myocardial band 3.0 IU/L, troponin I 0.03 ng/mL, C-reactive protein 0.59 mg/dL, white blood cell 8,900/µL, hemoglobin 11.4 g/dL, D-dimer assay 13.60 ug/mL. Cardiac enzyme levels were all within normal limits and nothing specific was found on the laboratory tests except an increase in D-dimer. The chest radiograph showed mild mediastinal widening with no active lung lesions (). From the data above, it was less likely that the cause of chest pain was from ACS. Therefore, an additional imaging study was performed: computed tomography (CT) angiography + 3-dimensional aorta (contrast) (). Surprisingly, the CT results showed aortic dissection type A starting from the distal ascending aorta with its distal extent just proximal to the right main renal artery (). The diameter of the ascending aorta was 50 mm and there was no evidence of coronary artery os involvement. The thoracic surgery department was immediately contacted and the patient had an emergency operation: replacement of ascending aorta, proximal arch, and innominate artery with Hemashield graft and open heart valvuloplasty of the aortic valve due to mild aortic regurgitation. The patient showed postoperative atrial fibrillation, which was managed by continuous infusion of amiodarone. Otherwise, she recovered well from the surgery and was discharged 18 days after the operation, with short-term follow-up at the outpatient clinic of thoracic surgery.