Acute Aortic Syndrome

An 83-year-old woman presented with mild, nonradiating, central chest pain. The results of her physical examination were unremarkable, and her pulses were symmetrical and bilaterally palpable. Her ECG revealed normal sinus rhythm with no acute ST/T-wave changes.Her transthoracic echocardiogram showed good left ventricular systolic function, with mild dilatation of the ascending aorta (4.5 cm) (Figure 1A), without evidence of pericardial effusion.Figure 1. A , Transthoracic echocardiogram (parasternal long-axis view) showing mildly dilated proximal aorta at 4.5 cm. B , Transthoracic echocardiogram (parasternal short-axis view at aortic valve level) showing large pericardial effusion with the collapse of the right atrium in diastole (thick arrow) suggesting cardiac tamponade. C , Transthoracic echocardiogram (subcostal view) showing a large pericardial effusion (thick arrow). D , Axial contrast-enhanced CT scan shows penetrating atheromatous ulcer of the aorta (thick arrow) filling with contrast material. Ao indicates the proximal aorta; AoV, aortic valve; CT, computed tomography; LA, left atrium; LV, left ventricle; PEff, pericardial effusion; RA, right atrium; and RV, right ventricle.Two hours later, she developed severe chest pain and collapsed. She was cold, clammy, and her blood pressure dropped to 60/30 mm Hg. Her jugular venous pressure was elevated. An urgent bedside transthoracic echocardiogram revealed cardiac tamponade (Figure 1B and 1C). Urgent computed tomography (CT) demonstrated a penetrating atheromatous ulcer (Figure 1D) with a large intramural hematoma.Acute aortic syndrome (AAS) refers to the acute presentation of closely related life-threatening entities having similar clinical features and challenges, including the aortic dissection, intramural hematoma, and penetrating atheromatous ulcer1 (Figure 2).Figure 2. Classification of acute aortic syndrome. A , Aortic dissection. B , Intramural hematoma. C , Penetrating atheromatous ulcer. Reprinted from Berger et al1 with permission from the publisher. Copyright © 2006, Radiological Society of the Netherlands.It has been suggested that aortic dissection, …