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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018 AFRICA e13
renal failure.5 A misdiagnosis at presentation may occur in up to
38% of AADs, as well as being discovered during post mortem
in 28% of cases without any prior identification or suspicion.15
Our patient presented with typical features of AAD, which
was initially diagnosed as myocardial infarction (MI), probably
due to the relative rarity of the condition compared to MI in our
setting. However, a thorough clinical assessment and high index
of suspicion may have picked up suggestive clinical features.
Furthermore, a chest X-ray, which usually shows enlargement of
the mediastinum with knobbing of the aorta in about 60% of the
cases was not done.16 This further emphasises the importance of
a chest X-ray among first-line investigations in the management
of acute chest pain.
According to the American Heart Association 2010 guidelines
for the management of acute thoracic disease, possible ECG
findings in the evaluation of AAD include: 30% normal ECG,
40% non-specific ST-segment changes, 26% left ventricular
hypertrophy and 15% signs of ischaemia.15 Our patient had
non-specific ST-segment changes consistent with myocardial
ischaemia. CECT angiogram of the thorax was used to confirm
the diagnosis of Standford type A AAD in the indexed case,
with the dissection extending to the iliac, mesenteric and left
renal arteries.
Although the diagnosis of AAD type A was made relatively
late in our patient, he was not operated on because of lack
of local cardiosurgical centres, financial constraints and
his refusal of evacuation to another country. The target
blood pressure and heart rate, as described in the literature,3
were achieved after six days of hospitalisation. Potential
contributing factors to the fatality included late referral and
diagnosis, initial treatment with LMWH at therapeutic dose
and aspirin, lack of local cardiosurgical centres for emergency
surgery, and severe sepsis.
Conclusion
Despite the relative rarity of AAD in sub-Saharan African
settings, this case highlights the importance of thorough early
clinical assessment and investigation in the emergency room of
patients with acute chest pain. Furthermore, limited resources
common in low-income settings contribute to this health burden.
The initiation of clinical registries is a potential avenue to
increase awareness around these fatal conditions and thereby
contribute to reduction of cardiovascular-related morbidity and
mortality.
We express our sincere gratitude to all doctors, nurses and medical students
who took part in the management of the patient. Written, signed, informed
consent was obtained from the patient’s next of kin for the publication of this
case and accompanying images. The patient’s confidentiality was maintained
throughout.
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