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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018
AFRICA
e9
Case Report
Acute type A aortic dissection involving the iliac and left
renal arteries, misdiagnosed as myocardial infarction
Paul Nkemtendong Tolefac, Anastase Dzudie, Sidick Mouliom, Leopold Aminde, Romuald Hentchoya,
Martin H Abanda, Charles Mve Mvondo, Vanina D Wanko, Henry N Luma
Abstract
Acute aortic dissection is the most frequent and deadly pres-
entation of acute aortic syndromes. Its incidence is estimated
at three to four cases per 100 000 persons per year. Its clinical
presentation may be misleading, with misdiagnosis ranging
between 14.1 and 38% in many series. A late diagnosis or
absence of early and appropriate management is associated
with mortality rates as high as 50 and 80% by the third day
and second week, respectively, especially in proximal lesions.
We report on the case of a 53-year-old man who presented
with type A aortic dissection, misdiagnosed as acute myocar-
dial infarction, who later died on day 12 of hospitalisation.
Although a relatively rare condition, poor awareness in Africa
probably accounted for the initial misdiagnosis. Thorough
investigation of acute chest pain and initiation of clinical
registries are potential avenues to curb related morbidity and
mortality.
Keywords:
aortic dissection, acute chest pain, hypertension,
outcome, case report
Submitted 3/10/16, accepted 2/10/17
Published online 3/11/17
Cardiovasc J Afr
2018;
29
: e9–e13
www.cvja.co.zaDOI: 10.5830/CVJA-2017-042
Cardiovascular diseases are the leading cause of death in the
Western world and are on the rise in developing countries.
1-3
Acute aortic syndromes include acute aortic dissection (AAD),
intramural haematoma, penetrating aortic ulcer and ruptured
thoracic aortic aneurysm.
3,4
AAD is the most frequent and lethal
presentation of acute aortic syndromes, with an incidence of
three to four cases per 100 000 persons per year.
5
There are several different classification systems of aortic
dissection. The two most commonly used formats are the
Debakey and Standford classifications, as shown in Table 1.
In the absence of treatment, AAD type A has worse outcomes,
with an initial mortality rate of 1% per hour, with 50 and 80%
of the patients expected to die by the third day and second
week, respectively. Progression of the dissection can be either
anterograde or retrograde from the initial tear, with resultant
malperfusion syndromes, acute coronary syndromes (ACS),
cardiac tamponade or aortic valve insufficiency.
6
Its clinical
presentation may be misleading with misdiagnosis ranging from
14.1 to 38% seen in many series.
7-10
The differential diagnosis of AADmay include acute coronary
syndromes, pericarditis, pulmonary embolism, acute pancreatitis
and peptic ulcer disease. AAD usually mimics ACS.
11
Factors
favouring misdiagnosis of AAD include clinical similarities with
common diseases such as ACS, low regional epidemiology, and
limited access to specific diagnostic imaging modalities in some
regions. In one study, it was shown that the commonest factors
Faculty of Medicine and Biomedical Sciences, University
of Yaoundé I, Yaoundé, Cameroon
Paul Nkemtendong Tolefac, MD,
ptolefac15@gmail.comCardiac Intensive Care Unit, Douala General Hospital,
Douala Cameroon
Anastase Dzudie, MD, PhD, FESC
Sidick Mouliom, MD, DSSc
Romuald Hentchoya, MD, DSSc
Faculty of Medicine and Biomedical Sciences, University
of Queensland, Australia
Leopold Aminde, MD
Cardiavascular Centre, Douala, Cameroon
Martin H Abanda, MD
Division of Cardiac Surgery, Shisong Cardiac Centre,
Kumbo, Cameroon
Charles Mve Mvondo, MD, DSSc
Radiology Unit, Douala General Hospital, Douala,
Cameroon
Vanina D Wanko, MD, DSSc
Internal Medicine Service, Douala General Hospital,
Douala, Cameroon
Henry N Luma, MD, DSSc
Table 1. Classification of acute aortic dissection
Standford classification
DeBakey classification
Type A
Type B
Type I
Type II
Type III
Dissection
involving
the proximal
aorta (ascend-
ing aorta,
aortic arch)
with or with-
out exten-
sion to the
descending
aorta
7,8
Dissection
limited to
the descend-
ing aorta
7
(but may be
extended to
the abdominal
segment)
Involving the
ascending
aorta and
a variable
amount of
descending
or thoraco-
abdominal
aorta
7
Dissection
limited to the
ascending
aorta
8
Dissection of
the descend-
ing aorta
either without
(IIIa) or with
(IIIb) involve-
ment of the
abdominal
aorta
7