Role of Supporting Examination in Investigating Non Specific Chest Pain to Diagnose Thoracic Aorta Aneurysm in Rural Setting: A Case Report

Author : M. Abduh, H. Nainggolan, J. Endang
Upload Date : 19-04-2018

Background: Thoracic Aorta Aneurysm (TAA) is defined as dilatation of more than 50% of normal thoracic aorta diameter and may potentially causes internal hemorrhage. Patients with TAA is often asymptomatic until the aneurysm expands and provide a challenge for clinicians in diagnosing patients with non-specific chest pain, especially in rural part of Indonesia with limited health care facility.
Case Description: A 53-year-old man came to ER with a chief complaint of chest pain radiating to the back. The onset of complaint was sudden and described as blunt and throbbing unpleasant sensation at first and became more like a sharp, painful tearing sensation during hospitalization. At the ER, the patient was conscious and fully aware, appeared to be in mild to moderate pain, he presented with a blood pressure of 160/110 mmHg, heart rate of 88x/minute, and respiratory rate of 30x/minute. He also had a previous history of poorly controlled hypertension. At first, the patient was admitted to high suspicion of acute coronary syndrome, due to present of risk factor and non-specific ECG changes. Chest X-Ray was performed on admission and the result showed that there is a homogenic, opaque shadow with a clear border at the level of 3rd to 6th thoracal vertebrae expanding into the mediastinum. Blood tests were taken and revealed hemoglobin 12.6mg/dL, ureum 28mg/dL, creatinin 0.8mg/dL, hematocrit 36%, leukocyte 14,300/mm3, thrombocyte 323,000/mm3 and troponin level was within normal limit. During hospitalization, on the second day, the patient reported that the chest pain was getting more severe and as a part of routine examination, echocardiography was performed and the result was dilatation of ascending aorta diameter of 4.2cm and thus aortic dissection was suspected. Later, more blood tests were taken and showed an elevated D-Dimer level of 2,249.16mg/dL. The patient was scheduled to undergo MSCT, but unfortunately the facility was not available in our hospital, and thus the patient was referred to Harapan Kita hospital for further examination and treatment. During hospitalization, the patient was treated as acute coronary syndrome patient at first and later the therapy was changed. He received bisoprolol 1x2.5mg, ramipril 1x5mg, amlodipin 1x5mg, atorvastatin 1x20mg and ISDN 3x5mg. He returned for post-hospitalization routine clinic visit, chest pain was resolved and the blood pressure was well-controlled.

Discussion: Thoracic aorta aneurysm is quite common among adults and often present to ER with non-specific complaints. This condition, if goes undiagnosed and untreated may threaten patient's life and therefore establishing diagnosis without delay is important. This patient was diagnosed as having acute coronary syndrome due to chest pain at first, further supporting examination helps to exclude the diagnosis and establish suspicion of TAA. Identification of risk factors during anamnesis needs to be emphasized as it helps to establish diagnosis and planning of further needed examination. Treatment of underlying disease and controlling risk factors are also needed to minimize the risk of aneurysm rupture. All modality of examination available should be considered in setting of minimum resources. Early diagnosis and treatment is possible and may improve patient's quality of life.

Conclusion: This case report shows that in rural setting with minimal availability of supporting examination, an early diagnosis and treatment of TAA is possible. Serial echocardiography should be considered in high risk patient presenting with non-significant chest pain to avoid delay in diagnosis and treatment.

KEYWORDS : aortic dissection, aortic aneurysm, echocardiography

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