A 62 yo patient with a previously diagnosed spontaneous coronary artery dissection (SCAD) presents with sudden onset 10/10 central severe chest pain. Examination is normal, with no pulse deficit and no murmur. The ECG is normal, the initial troponin is normal. Cardiology are not interested unless the followup 3 hour troponin is raised. (40 minutes read)
Could this be a thoracic aortic dissection? You may expect a troponin rise in a proximal dissection (as the proximal aorta contains troponin), but a normal troponin doesn’t rule it out.
The patient scores a 1 in the aortic dissection detection (ADD) risk score due to the pain features. Would you send this patient home if the D-dimer were normal? Does the fact that the patient have SCAD, increase her risks of a thoracic dissection? Would you perform a CT angiogram? Is there something more we can do to define a lower risk group?
Perhaps the new PROFUNDUS Study can help.
Acute Aortic Syndromes(AAS) have a significant, time dependent mortality, which can approach 1-2% mortality per hour. We investigate many patients with suspected AAS in the emergency department, with a low yield of true positives. The imaging of choice is CT angiography.
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