JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
DIAGNOSIS
REFERENCES
1. Slater EE, DeSanctis RW. The clinical recognition of dissecting aortic aneurysm. Am J Med 1976;60:625-633. 2. Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: Experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642-651. 3. Hagan PG, Nienaber CA, Isselbacher EM, et al. International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA 2000;283:897-903.
Normal sinus rhythm; left atrial enlargement [Negative terminal P-wave deflection in lead V1 > 0.1 mV, when 1.0 mV = 10 mm, and duration > 0.04 ms]; left ventricular hypertrophy [RI > 1.3 mV; Lewis index (RI+SIII) – (RIII+SI) > 1.7 mV]; nonspecific ST-T changes; prominent U waves. Just as important as the ECG findings was what was not found, i.e., any change specific for myocardial ischemia. Although the history was compatible with an atypical presentation of myocardial ischemia or a variety of gastrointestinal problems, the long history of systemic hypertension, extremely high blood pressure, back and abdominal pain in the absence of ECG findings of ischemia were textbook-perfect for descending thoracic aortic dissection extending into the abdominal aorta. 1-3 The chest radiograph showed a huge aortic knob and descending thoracic aorta, clear lungs, and a prominent left ventricle. Computed tomography confirmed that the dissection began just distal to the origin of the left subclavian artery and extended into the abdominal aorta. The renal, celiac, superior and inferior mesenteric arteries were patent, but some filled from the true lumen and some from the false lumen. The patient was managed in the intensive care unit with an intravenous nitroglycerin drip to lower blood pressure and an esmolol drip to decrease aortic dP/dt in an attempt to prevent further dissection. Labetalol was added because the blood pressure drop was insufficient. All beta blockers had to be discontinued when bronchospasm necessitated tracheal intubation. Intravenous sodium nitroprusside then became the short-term means of controlling the blood pressure. The prevalence of coronary artery disease and the frequency of acute coronary syndromes have led us to think first of myocardial ischemia as the cause of any pain between the jaw and the umbilicus. As a result, other diagnoses have been missed or delayed, and aortic dissection has been high on that long list. 1-3
Dr. Glancy is an emeritus professor of medicine (cardiology) at the Louisiana State University Health Sciences Center in New Orleans, Louisiana.
144 J La State Med Soc VOL 169 SEPTEMBER/OCTOBER 2017
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