Authors: Dr Abdullah Rana

Abstract

Case Series

Case 1:
A 54-year-old man with known ischaemic heart disease presented with central chest pain identical to his previous myocardial infarction. He was hypertensive with elevated troponin and managed as non-ST elevation myocardial infarction. Transthoracic echocardiography performed the following day demonstrated a dilated aortic root. CT aortography confirmed a Type A dissection extending into the left carotid artery. He underwent urgent surgical repair and made a full recovery.

Case 2:
A 54-year-old man presented with agitation, hypotension, and diffuse ECG changes. He was unable to provide history and initially appeared toxic or metabolically unwell. Bedside echocardiography revealed pericardial tamponade. CT confirmed extensive dissection from the aortic root to the bifurcation. Despite emergency surgical intervention, he died intraoperatively.

Case 3:
A 69-year-old woman presented with sharp central chest pain. D-dimer and serial troponins were negative. She declined admission and self-discharged. She re-presented later the same day following collapse at home, with shock and a Glasgow Coma Scale score of 6. CT aortography demonstrated a Type A dissection with tamponade. She died shortly after intubation and transfer to intensive care.

Case 4:
A 55-year-old man experienced transient chest pain with brief ST-segment elevation in a single lead, which resolved prior to emergency department arrival. Marked hypertension prompted immediate CT aortography, confirming extensive dissection from root to bifurcation. He was managed conservatively and discharged after 18 days. Subsequent investigations suggested underlying vasculitis.

Discussion

This case series demonstrates the extreme diagnostic variability of TAD and its capacity to masquerade as more common conditions. Misleading ECG findings, false-negative biomarkers, and transient symptoms may result in inappropriate treatments or delayed imaging.² Bedside point-of-care ultrasound played a pivotal role in identifying tamponade and expediting diagnosis in two cases. Emergency physicians must maintain a high index of suspicion and prioritise early imaging when the clinical picture is incongruent.³

Conclusion

Thoracic aortic dissection remains a diagnostic challenge with devastating consequences if missed. These cases highlight the importance of clinical vigilance, early bedside echocardiography, and prompt CT imaging when presentations do not fit typical patterns.

References

1. Hagan PG, et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283(7):897–903.
2. Erbel R, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. 2014;35(41):2873–2926.
3. Nazerian P, et al. Diagnostic performance of focused cardiac ultrasound in suspected aortic dissection. Acad Emerg Med. 2014;21(6):605–610.

Keywords: aortic dissection, thoracic, thoracic dissection, myocardial infarction, d-dimer, troponin, syncope, collapse, CT Aorta, CT Aorta with contrast