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The Potentially Harmful Dimension of Pauci-Symptomatic Aortic Dissection

      To the Editor:
      The pauci-symptomatic presentation of aortic dissection reported by Schattner et al
      • Schattner A
      • Dubin I
      • Glick Y
      Pauci-symptomatic aortic dissection.
      has, as its counterpart, the pain-free presentation of aortic dissection where only one of the complications is the presenting feature. This pauci-symptomatic presentation has a potentially harmful dimension when there is a risk of iatrogenic harm during management of the presenting pauci-symptomatic feature.
      A prime example is the presentation of aortic dissection with stroke, in the total absence of back pain, chest pain, or pain anywhere else.
      • Imamura H
      • Sekiguchi Y
      • Iwashita T
      • et al.
      Painless acute aortic dissection. Diagnostic, prognostic and clinical implications.
      This was a feature in 5 of 1637 patients who were admitted to the National Cerebral and Cardiovascular Center between 2007 and 2013 with suspected ischemic stroke. All 5 had neither chest pain nor back pain. All 5 had “onset-to-door time” of <4 hours, arguably making some of them eligible for the 3-hour window of opportunity to benefit from thrombolytic therapy.
      • Bhaskar S
      • Stanwell P
      • Cordato D
      • Attia J
      • Levi C
      Reperfusion therapy in acute ischemic stroke: dawn of a new era?.
      However, attribution of stroke to aortic dissection was a contraindication to that treatment modality, given its attendant hemorrhagic risk.
      • Huang YC
      • Sung SF
      • Liu KT
      Painless acute aortic dissection may present as a stroke; risky markers that could be identified on hospital arrival.
      Presentation with pain-free ST-segment elevation is another example of pauci-symptomatic aortic dissection, which has the potential to generate thrombolysis-related iatrogenic harm. In one example, the presenting feature was breathlessness but without chest pain, back pain, or pain anywhere. The blood pressure was 210/135 mm Hg, and a diastolic murmur was detected. The electrocardiogram showed ST-segment elevation in leads V1-V6. Portable echocardiography disclosed aortic regurgitation and a small pericardial effusion. Repeat echocardiography showed a dissection flap and a dilated ascending aorta. Subsequently, the patient had a successful aortic repair.
      • Ayrick C
      • Cece H
      • Aslan O
      • Karcioglu O
      • Yilmaz E
      Seeing the invisible: painless aortic dissection in the emergency setting.
      In this instance, pretest probability of aortic dissection was generated by the presence of hypertension and aortic regurgitation. Furthermore, the pain-free presentation made him ineligible for either thrombolysis (which would have generated a risk of cardiac tamponade in a patient who already had echocardiographic documentation of pericardial effusion) or percutaneous coronary intervention, given the time-sensitive criteria for the administration of those 2 treatment modalities.
      • Mcnamara RL
      • Herrin J
      • Wang Y
      • et al.
      Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction.
      ,
      • Menees DS
      • Peterson ED
      • Wang Y
      • et al.
      Door-to-balloon time and mortality among patients undergoing primary PCI.

      References

        • Schattner A
        • Dubin I
        • Glick Y
        Pauci-symptomatic aortic dissection.
        Am J Med. 2021; 134: e201-e202
        • Imamura H
        • Sekiguchi Y
        • Iwashita T
        • et al.
        Painless acute aortic dissection. Diagnostic, prognostic and clinical implications.
        Circ J. 2011; 75: 59-66
        • Bhaskar S
        • Stanwell P
        • Cordato D
        • Attia J
        • Levi C
        Reperfusion therapy in acute ischemic stroke: dawn of a new era?.
        BMC Neurol. 2018; 18: 8
        • Huang YC
        • Sung SF
        • Liu KT
        Painless acute aortic dissection may present as a stroke; risky markers that could be identified on hospital arrival.
        J Acute Med. 2017; 7: 93-100
        • Ayrick C
        • Cece H
        • Aslan O
        • Karcioglu O
        • Yilmaz E
        Seeing the invisible: painless aortic dissection in the emergency setting.
        Emerg Med J. 2006; 23: e24
        • Mcnamara RL
        • Herrin J
        • Wang Y
        • et al.
        Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction.
        Am J Cardiol. 2007; 100: 1227-1232
        • Menees DS
        • Peterson ED
        • Wang Y
        • et al.
        Door-to-balloon time and mortality among patients undergoing primary PCI.
        N Engl J Med. 2013; 369: 901-909