Tuesday, December 2, 2014

A 50-something with severe chest pain and a normal ECG

A 50 something with no past history presented with sudden severe substernal chest pain with no radiation or associated symptoms.  The clinicians were very impressed with his presentation and were sure he was having an MI.  Here is his initial ECG:
Not very revealing.  They had expected a positive ECG.

A chest x-ray was completely normal.

The first troponin was negative.  

The pain persisted and another ECG was recorded 80 minutes later:
There is now some nonspecific ST depression in V5 and V6.

The second troponin returned negative at 5 hours.  The patient's pain persisted.

The clinicians were certain that something serious was wrong and were not convinced by the ST depression that it was ACS, so they performed a bedside ultrasound.

Here is the parasternal short axis:

There is good function and normal wall motion

Here is the parasternal long axis:

The emergency physician thought he saw a flap in the aorta (the echo free area behind the left atrium (see still image with arrow below):

The arrow points to something that, on the video, is apparently moving inside the aorta on the video

So the emergency physician took a look at the aorta through the suprasternal notch:

You can see a flap in the aorta

Here is a still picture with arrows pointing to the flap:
Here you can easily see the flap

Here is the CT scan:
Here you can clearly see the dissection flap

He went to the operating room and had a successful graft placed.  As I understand it, he was not a candidate for intravascular stent placement.

Learning point:

I don't usually do an ED ultrasound on every chest pain patient.  Maybe one should.  But in this case there were clues that something was wrong:

1.  Sudden pain
2.  Never had before
3.  Looked ill and in distress
4.  Could not be explained by the ECG
5.  Troponins negative.

One could argue that this could simply be suspected and he could get a d dimer, the CT if positive, or simply go straight to CT.

Fair enough.

But this is an easy screening test that one could do on more patients with unexplained chest pain.


  1. do you have a copy of the CXR

    1. I looked at it, but I don't have it. I am very good a reading CXRs, and scrutinized it for any sign of dissection. There was none. 10% of dissection (large registry) have no evidence of it on plain CXR.

  2. The one dissection I diagnosed with echo had minimal pain over the right sternoclavicular joint, reproducible with pressure, was in no distress, had a BP of 110/70 mmHg. I didn't think she'd have an aortic dissection, but she did have a weird systolic murmur and a history of dilated aorta and aortic regurgitation. Luckily there was a flap in the proximal aorta that I could see with echo, her suprasternal window was not good.

  3. Sorry, has the pațient also hypertrophic cardiomiopathy?

    1. I see why you would say that but other views did not substantiate

  4. What do You think about the aortic valve in pst long axis view?

    1. It appears to be a dilated aortic, but I don't think the view is good enough to say for sure.

  5. Very nice! Unless I'm mistaken in what anatomy I'm looking at, it looks like you can also see the flap in the PSA view as well (which is where it first caught my eye).

    1. Parasternal short axis, you mean. Yes, I think you're right, Vince.

  6. Aren't there U waves visible in V2-V5 on both ECGs?and could they have any significance in the case of a patient with severe chest pain?thank you.

    1. There are U-waves indeed, but they are normal. U-waves are a normal finding on an ECG. If they are too large or inverted, then they are pathological. These are not. For some pathological ones, see these cases: http://hqmeded-ecg.blogspot.com/search/label/U-waves

  7. In my opinion the apparent structure in the descending aorta in the TTE PLX is a ghost artefact from the AV-groove. I suggest that it was a very fortunate misinterpretation. Or?


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