Question

A 65-year-old patient presented with chest pain with ECG changes. However, his transthoracic ECHO was normal and coronary arteries were normal on coronary angiography done through right radial artery. There was suspicion of aortic dissection while carrying out coronary angiography.
How will you evaluate him further?

Hint:

In patients with suspected aortic dissection, CT or MRI angiography is crucial for confirming the diagnosis and assessing the extent of the dissection.

Answer 1

Step 1: Initial clinical evaluation.
In the setting of suspected aortic dissection, it is important to obtain a detailed clinical history, including risk factors such as hypertension, connective tissue diseases (like Marfan syndrome), or a history of aortic disease. A thorough physical examination should be conducted to check for signs of shock, a difference in blood pressure between limbs, or a new heart murmur.

Step 2: Imaging studies.
The gold standard for diagnosing aortic dissection is CT angiography (CT of the chest, which provides detailed imaging of the aorta and helps to confirm the presence of a dissection and the extent of involvement. If CTA is unavailable, MRI of the aorta is also highly effective. An aortogram during coronary angiography can also help visualize the aorta and any potential dissection, especially if there is suspicion during the procedure.

Step 3: Laboratory tests.
Blood tests, including D-dimer, may be helpful in assessing the likelihood of aortic dissection, though it is not diagnostic. Elevated D-dimer levels may indicate acute pathology such as dissection, although other conditions can also elevate this marker.

Step 4: Conclusion.
To evaluate further, the patient should undergo CT or MRI angiography to confirm the diagnosis of aortic dissection. Invasive aortography can be performed if necessary.