MISSED DIAGNOSIS OF ACUTE TYPE A AORTIC DISSECTION TREATED AS NON-ST ELEVATION MYOCARDIAL INFARCTION: A TEACHABLE MOMENT

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute type A aortic dissection (ATAAD) is a life threatening emergency, with mortality rate of 1% to 2% per hour during the first 24 48 hours, reaching 75% at 2 weeks and 91% 1 year, if left untreated. CASE PRESENTATION: 35-year-old male, nonsmoker history untreated hypertension (HTN), presented sudden onset, severe, non-radiating, "twisting" mid-sternal chest pain. Initial vital signs showed an elevated blood pressure (BP) 210/132 mmHg in both arms, heart 85 beats/minute, afebrile arterial saturation 100% on room air. He was severe distress due pain sweating profusely. The cardiac examination did not reveal murmur, rub or gallop, his radial pulse regular, equal bilaterally. Electrocardiogram (EKG) sinus rhythm T-wave inversions inferior lateral leads. work up significant for creatine kinase (CK) 636 U/L (normal range < 200 U/L). Chest X-ray cardiomegaly, mediastinal widening infiltrates. CT including iliac arteries - chest, abdomen pelvis without contrast read as negative dissection, aneurysm, pulmonary embolism pericardial effusion. Subsequent labs were trending CK 751 U/L) Troponin 0.42 ng/ml 0.10 ng/ml). In view rising biomarkers, dual anti-platelets anticoagulants acute coronary syndrome (ACS) started. transthoracic echocardiogram (TTE) ordered which performed 12 hours later flap proximal ascending aorta, moderate eccentric regurgitation, bicuspid valve. DISCUSSION: Some reports scanning have reported sensitivities close 100%, but false scans are well recognized. True sensitivity likely lower 94% specificity around 77% 100%. False results can be secondary reader's error true image. Second imaging tests frequently obtained cases suspected transesophageal echocardiography being most commonly used modality. Point Care Ultrasound (POCUS) has become commonplace many critical care settings, studies shown good diagnosis ATAAD [5]. This may allow treating clinician diagnose point care, avoiding clinical time dissociation inherent consultative echocardiography. Intimal visualization 67-80% 99 CONCLUSIONS: Our case reminder that CTA rule out second diagnostic modality should suspicion high. pre-test probability dictate imaging/testing warranted its urgency. REFERENCE #1: Afifi RO, Sandhu HK, Leake SS, et al.: Determinants Operative Mortality Patients With Ruptured Type Aortic Dissection. Ann Thorac Surg. 2016, 101:64-71. 10.1016/j.athoracsur.2015.07.007 #2: Abbas A, Brown IW, Peebles CR, Harden SP, Shambrook JS: role multidetector-row diagnosis, classification management syndrome. Br J Radiol. 2014, 87:20140354. 10.1259/bjr.20140354 #3: Wang Y, Yu H, Cao Wan Z: Early Screening Dissection Point-of-Care by Emergency Physicians: Prospective Pilot Study. Med. 2020, 39:1309-15. 10.1002/jum.15223 DISCLOSURES: No relevant relationships SYED ABBAS, source=Web Response Syeda Hamadani, Seth Koenig, Response, value=Honoraria Removed 05/16/2021 Abeer Zeeshan,