A 92-year-old woman with a ruptured ascending aortic aneurysm and hemopericardium presented atypically with ST-segment changes and improved hemodynamics despite administration of anticoagulation.
Case Report (n=1)
This case highlights the diagnostic challenge of aortic rupture presenting with atypical features mimicking acute coronary syndrome and the importance of maintaining a high index of suspicion.
Abstract Introduction Rupture of a thoracic aortic aneurysm is a life-threatening cardiovascular emergency, with less than half of patients reaching the emergency department alive, and an overall mortality rate as high as 98%. Patients classically present with chest pain and hemodynamic instability, but contained ruptures may have variable presentations that make early recognition challenging. We present the case of an elderly woman who upon ICU admission appeared hemodynamically stable with negative cardiac biomarkers but was later found to have a ruptured ascending aortic aneurysm with hemopericardium. Case A 92-year-old woman presented to the ED for chest pain that began after an episode of bloating the night prior. On arrival, she was unresponsive, hypotensive at 60/50, and tachycardic with cold, mottled skin on exam. She was resuscitated and started on vasopressors. Serial EKGs found ST elevation in aVR, depression in V3-6 and I/II. Initial troponin of 22 and lactate of 6.4. She was started on heparin drip after which her mentation improved and tachycardia resolved. Her APACHE II score was 8 on admission to the ICU. Transthoracic echocardiography revealed EF 55-60% and 2 cm fibrinous pericardial effusion, without diastolic collapse. CT angiography showed an ascending aortic aneurysm with contrast extravasation into the pericardium, circumferential intramural hematoma, and underlying dissection. Emergent cardiothoracic surgery evaluation was recommended, however the patient had earlier expressed her wishes to be DNR/DNI. Discussion Patients with thoracic aneurysm ruptures often deteriorate rapidly without intervention, but can have atypical presentations when associated with cardiac tamponade. Our patient presented with ST-segment changes on EKG, leading to an initial working diagnosis of acute coronary syndrome, supported by improvement after initiating heparin and vasopressors. However normal troponin levels prompted further investigation, which led to the discovery of the ascending aortic rupture and hemopericardium. Pericardiocentesis in the setting of rupture has usually been contraindicated, as rapid and aggressive drainage may precipitate a worsening leak from the aorta into the pericardium. Curiously, this patient experienced improvement in her hemodynamics despite administration of anticoagulation. Additionally, absence of diastolic collapse underscores that tamponade physiology may not always be present even in the presence of a large effusion with active extravasation. This case highlights the diagnostic challenge associated with aortic rupture in the presence of cardiac tamponade and the importance of maintaining a high index of suspicion in patients with unexplained hypotension and chest pain. This abstract is funded by: none
Siddiqui et al. (Fri,) conducted a case report in Ruptured thoracic aortic aneurysm with hemopericardium (n=1). A 92-year-old woman with a ruptured ascending aortic aneurysm and hemopericardium presented atypically with ST-segment changes and improved hemodynamics despite administration of anticoagulation.