#005 Curveball Case Study - Dissecting an NSTEMI

Handover from A&E -

45M referred to medics via A&E for chest pain.

First troponin - 42

ECG - Inferior changes, TWI nil ST elevation

Discussed with cardiology SpR who deemed findings more suggestive of LV strain pattern

Tx - DAPT and fondaparinux

CXR - clear, no widened mediastinum

Seen by medics 6 hours after initial presentation, approx. 10pm after handover. Handover received from day medical SHO by night SHO. Patient had presented at 4pm. Chest pain started earlier that morning.

12 hours chest pain

Started severe 8/10, eased off now 3/10

Gradual onset when walking whilst at work

Got home and pain was much better

Radiated to his back (not mid-scapular) – non-specific

No SOB/cough/haemoptysis/fevers/no GI Sx/urinary Sx

No focal neurology

HTN - takes ramipril

Works as builder

Smoker - 20 per day for 20 years

No alcohol

Lives with family, 2 young children

Arabic decent

Appears in mild discomfort, slightly clammy

A – Patent

B – Chest clear, RR 18, sats 97% on RA

C – HS - aortic diastolic murmur, CRT <2s, HR 82 regular, BP 122/70*, marked radial-radial delay, calves SNT, nil pedal oedema

D – GCS 15

E – Abdo SNT, apyrexic

*hypotensive for this patient

Bloods – Hb 120, nil previous for comparison

VBG – pH 7.36, lactate 3, everything else NAD

Fast scan by ED SpR (after some pushback) – suspicious for dissection

CT aortogram – Aortic dissection extended to the carotids and descended to the infra-renal arteries (stopping just before) - Debakey type A. Had caused incompetence of the aortic valve leading to regurgitation/murmur

Plan

- Referred to CTS

- Arterial line inserted for BP monitoring

- Labetolol infusion to protect the arteries by keeping the BP as low as possible to prevent more shearing. Replaced the aortic root and needed repair of the other arteries.

- Transferred to GSTT with anaesthetic escort straight to CEPOD for 8 hour operation

- Transferred to ITU post-op stayed approx. 10 days, did not need X-match at this point

Learning points:

• Be aware of diagnostic overshadowing and maintain an open mind about the working diagnosis

• A patient with a history of poorly or partially controlled hypertension presenting with normal blood pressure readings should be treated as hypotensive