Hrev_master [page 10] [Emergency Care Journal 2025; 21:13751] Emergency Care Journal 2025 volume 21:13751 Abstract Type B aortic dissection is a relatively rare clinical condition with, however, a significant clinical impact and therefore an early diagnosis is necessary. The clinical presentation is highly variable depending on the aortic district involved and the presence of signs secondary to hypoperfusion. This peculiarity makes diagnosis even more difficult. We describe the case of a 52-year-old patient who presented to our emergency department with significant chest pain and crisis; his medical history was silent and there were no known cardiovascular risk factors. The ultrasonographic, electrocardio- graphic, laboratory and semeiological findings and the resulting diagnostic pathways were totally negative. Only advanced diag- nostics allowed the diagnosis of aortic dissection. This case allows us to reflect on the interpretation of blood chemistry tests and the application of diagnostic scores/pathways in everyday clinical practice, especially in less defined clinical pictures. Introduction Acute aortic syndromes is a potentially fatal condition that requires early diagnosis and immediate targeted treatment. The epidemiology is still poorly understood due to the high pre-hospi- tal mortality, the prevalence is estimated to be around 0.2-0.8%, while population-based studies report incidences of 2.5-7.2 per 100,000 population/year, underlining a progressively increasing trend in recent years;1-4 it affects mainly the male sex (65%) with a peak around the 7th decade of life (63 years). The clinical presen- tation can be subtle, especially in the absence of pre-clinical risk factors (cardiovascular, collagenopathies, family history) and in the absence of blood test with high specificity and sensitivity. We present the case of a 52-year-old patient with very intense chest pain, non-suggestive laboratory findings, negative diagnostic scores and a diagnosis of “type B” aortic dissection. Case Report In September 2024, a 52-year-old Caucasian man was brought to the Emergency Department complaining of acute chest pain of severe intensity that had been present for about three hours. He reported waking up suddenly complaining of typical thoracoalgia (numerical rating scale, NRS 9/10), described as persistent, with a tearing quality, resembling a knife-like sensation and not modifi- able by breath nor exacerbated by mobilisation. He reported that he had never experienced such pain. Full medical history was assessed and collected. Patient works as a laborer in a construction company and had no significant family medical history. The patient’s past medical history was also negative, he denied taking drugs, was non-smok- er, and drank only socially. The patient presented conscious with hemodynamic stability. Very agitated and in pain (NRS 9/10). The vital signs were in the normal range (heart rate 66 bpm) with the exception of the blood pressure trending towards hypertension (180/90 mmHg) despite the administration of nitroglycerine (2 puffs of nitroglycerine, 0.60 mg) during transport. There were no signs of diaphoresis and fever. On physical examination there were no major alterations: the hearth sounds were rhythmic without car- diac murmurs, radial pulses were palpable, symmetrical and nor- mosphygmic. In the lower limbs there were no signs of ongoing deep vein thrombosis. Due to the persistence of the severe chest pain, morphine 4mg was administered immediately plus 2 mg after one hour and due to the concomitant hypertensive blood pressure trend (PAS 200-180mmHg, PAD 85-95mmHg) a further 2 puffs of nitroglycerine were administered with partial benefit on the algia and a reduction in systolic values. Correspondence: Marco Passaretti, Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072 Pieve Emanuele (MI), Italy, E-mail: marco.passaretti@humanitas.it Key words: aortic dissection, score, pathways, D-Dimer Conflict of interest: the authors have no financial or proprietary interests in any material discussed in this article. Ethics approval and consent to participate: no ethical committee approval was required for this case report by the Department, because this article does not contain any studies with human partic- ipants or animals. Informed consent was obtained from the patient included in this study. Patient consent for publication: the patient gave his written consent to use his personal data for the publication of this case report and any accompanying images. Availability of data and materials: all data underlying the findings are fully available. Received: 4 March 2025. Accepted: 11 July 2025. Early view: 22 August 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13751 doi:10.4081/ecj.2025.13751 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. A silent case of aortic dissection: a case report Marco Passaretti,1 Carlo Maino2 1Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan; 2Head of Emergency Department Humanitas Mater Domini, Castellanza, Varese, Italy Initial diagnostics The following diagnostic investigations were performed: i) Electrocardiogram (ECG): SR with HR of 60 bpm, left axis devia- tion, non specific and diffuse repolarization abnormalities; ii) ABG analysis (Arterial Blood Gas): ph 7,38, no electrolyte alterations, BE -0.4, Lat 0.7; iii) Point-of-Care ultrasound (POCUS, convex probe 5 MHz): lung sliding is present in all examined zones, no signs of pneumothorax, A-lines, no effusions, no free fluid at Morrison’s, splenic-renal and Douglas pouch, no pericardial effu- sion, aorta with normal course and diameter (21 millimeters) (Figure 1); iv) cardiac echoscopy (sector probe 2.5 MHz): no peri- cardial effusion, no right section dilatation, no dyskinesias. No signs of dissection at aortic root level nor signs of aortic regurgita- tion (Figure 2). The haematochemical exams were as reported in Table 1. Negative troponin and D-dimer results are emphasised. In view of the non-unambiguous interpretation of the clinical picture, particularly in view of the laboratory findings (negative troponin and D-dimer) and the persistence of the painful symp- toms, the differential diagnosis of chest pain was made: i) cardio- vascular: Acute Coronary Syndrome (ACS), acute aortic syn- drome, Pulmonary Thromboembolism (PTE); ii) pulmonary: pul- monary infarction, pleurisy, pneumothorax; iv) gastrointestinal: oesophagitis, Gastro-Oesophageal Reflux Disease (GERD), “pill oesophagitis”, gastric/duodenal ulcer; v) mediastinal: mediastini- tis; vi) “wall”: osteomuscular; vii) psychiatric. The following causes were excluded: pulmonary (negative point-of-care ultrasound, D-dimer and CRP not suggestive), gas- trointestinal (negative history, symptoms not suggestive), medi- astinal (clinic and bioumoral findings not suggestive), wall (nega- tive history, symptomatology not suggestive) and, finally, psychi- atric (negative history). In the suspected life-threatening cardio-thoracic-vascular aeti- ology (ACS vs. PTE vs. acute aortic syndrome), the main diagnos- tic scores/pathways were calculated: i) HEART Pathway5: 3 points (low risk of 6 weeks MACE, 0.9-1.7% ), negative troponine at one and three hours (rule-out for SCA); ii) Wells’s Score6: 3 points (low risk), Geneva-R Score7): 0 points (low risk), YEARS Pathway8: rule-out for TEP (0.43%); iv) ADD-RS (Aortic Dissection Detection Risk Score)3,4,9: 1/3 with subsequent rule-out for negative D-dimer (414 ng/ml, RR 0-500 ng/ml FUE). Approximately 4 hours after admission and a total of 12 mg of morphine, a significant improvement in the algic symptoms was observed (NRS 2/10) but pressure values above the limits persisted (mean systolic blood pressure 175 mmHg, mean diastolic blood pressure 95 mmHg, hearth rate 60-65 bpm) so ramipril 5 mg was administered. In light of the marked improvement in clinical condition and the blood pressure, it was initially decided to discharge the patient. However, in view of the characteristics of the thoracic pain symp- toms (intensity, type, duration, onset) and the need for large doses of a major opioid in a naive patient (12 mg of morphine) to resolve the algic symptoms, it was decided to perform second-level diag- nostics by requesting chest CT angiography. Chest CT angiography (CTA) revealed an intramural haematoma of the thoracic aorta extending from the aortic arch (distal to left subclavian artery’s site of emergence, where there are also a few wall calcifications of the aortic arch), involving the entire descending aorta and currently exhausting at the thoraco- abdominal passage, maximum thickness 12 mm. At the level of the distal section of the thoracic aorta in the context of the intramural haematoma, there was an arterial blush of 1.5 cm compatible with the lesion of the intima in a Stanford B-type aortic dissection (Figure 3). Because of the diagnostic finding, the patient was sent to a cen- ter with cardiac and vascular surgery for the continuation of the conservative versus endovascular/open medical treatment course. Case Report Figure 2. Cardiac echoscopy: no signs of dissection at aortic root level nor signs of aortic regurgitation. Figure 1. POCUS: aorta with normal course and diameter (21 mil- limeters). Table 1. Haematochemical exams. White blood cell 10.9/mmc Haemoglobin 13.8 g/dl Platelets 371000/mmc Urea 34.5 mg/dl Creatinine 0.82 mg/dl LDH 207 IU/L CRP 0.65 mg/dl D-dimer (FEU) 414 ng/ml Troponin (0h) 13.5 ng/ml Troponin (1h) 12.26 ng/ml [Emergency Care Journal 2025; 21:] [page 11] Follow-up In the light of type B of dissection and the absence of symp- toms of hypoperfusion, after the emergency transfer of the patient to the HUB hospital, a conservative medical approach was chosen, initially through intravenous administration of labetalol for 72 hours, followed by gradual titration of oral antihypertensive thera- py (Ramipril 5 mg bid, Doxazosin 2 mg bid, Nitroglycerin 15 mg 1/day, Nebivolol 5 mg die, Rosuvastatin 10 mg die, amlodipine 5 mg bid) with good control of blood pressure and planning close radiological follow-up. Last evaluation with CT angiography (November 2024) revealed a markedly reduced hyperdensity of the thrombus in the pre-contrastographic phase (max thickness of about 6 mm on the left postero-lateral side of the descending thoracic aorta). Two small saccular regions of enhancement protruding from the aortic lumen in the context of the previous intramural haematoma, one on the left lateral side, the other on the right postero-lateral side (max. 8 mm at this level, where it causes small bulging of the media and the adventitia above) were observed: these formations are compat- ible with ULPs (ulcer like projections) of the intima. There is mild contrastographic enhancement of the adjacent thrombus, with hyperemia of the adventitial wall. Clinical vascular surgical fol- low-up is recommended. Discussion Type B aortic dissection according to Stanford’s classification accounts for approximately 25-30% of acute aortic syndromes with a hospital mortality rate of medical treated patients of approx- imately 10% and the 3-year survival rate is 78% for those treated with medical management alone.10,11 Chest pain accounts for 5-9% of admissions to the emergency department, and early detection and subsequent definition of the diagnostic-therapeutic course becomes of primary importance. We decided to present this case in order to emphasize the need for a rational use of diagnostic insights and decision-making algorithms. We focused, especially, on the use and interpretation of the D-dimer for diagnostic rule-out; a role highlighted in the EACTS/STS LG 2024: The D-dimer blood test is extremely helpful in the emergency setting. If the D-dimer is negative, the patient does not have an aortic dissection.3 Indeed, circulating D-dimer levels increase in most patients with AAS.12 Conversely, low levels of D-dimer argue against AAS, most strongly in patients at low PTP (Pre Test Probability), potentially allowing rule-out without further tests. However, although D-dimer is a high-sensitivity test, it cannot be used alone to rule out acute aortic syndrome, as demonstrated by this case. In recent years, several studies have highlighted that in patients with low Pre-Test Probability (PTP), the integration of the Aortic Dissection Detection Risk Score (ADD-RS) and D- dimer testing can safely rule out acute aortic syndrome (AAS) with high sensitivity. Pooled sensitivity was 99.9% (95% confidence interval [CI]: 99.3% to 100%, I² = 0) for ADD-RS = 0 combined with D-dimer < 500 ng/mL or age-adjusted D-dimer; 98.9% (95% CI: 97.9% to 99.9%, I² = 0) and and LR- 0.02 for ADD-RS ≤ 1 and D-dimer < 500 ng/mL as in the present case.13 Furthermore, the diagnostic accuracy of integrating POCUS with pre-test probability (PTP) and D-dimer testing has also been investigated. This integrated approach has been shown to safely rule out Acute Aortic Syndrome (AAS): a low POCUS-integrated PTP combined with a D-dimer < 500 ng/mL yielded a sensitivity of 100% (95% CI: 97.9-100), while an ADD-RS ≤ 1 combined with a D-dimer < 500 ng/mL showed a sensitivity of 98.8% (95% CI: 97.1-100).14 However, this case highlights the need to avoid relying solely on the diagnostic accuracy of scoring systems and their combina- tions. It underscores the crucial importance of a multiparametric evaluation that incorporates laboratory findings, imaging results, and clinical presentation. Clinical assessment should take into account the nature of the pain, its temporal progression, and the patient’s response to therapy. Furthermore, it is worth highlighting as a potential subject of further investigation the temporal correlation between the onset of symptoms and the timing of D-dimer measurement. In this partic- ular instance, the blood sample was taken five hours after symptom onset and was not subsequently repeated. In this case, the absence of cardiovascular risk factors, nega- tive initial test results, and low diagnostic scores led to a delayed clinical suspicion. The pre-test risk was low, and D-dimer was neg- ative, which initially supported the decision to forgo further diag- nostic imaging such as Computed Tomography Angiography (CTA). Only the “human factor” understood as instinct mixed with experience made it possible to reach the correct diagnosis by means of advanced diagnostics, thus underlining the importance of always considering serious pathologies in the presence of intense and persistent chest pain, even in the absence of instrumental and above all laboratory alterations; highlighting how the presentation of aortic dissecative disease can be very varied and “clinically sub- dued”. Conclusions This case emphasizes the importance of a comprehensive clin- ical evaluation, semeiotics and view of the patient as a whole regardless of laboratory findings, literature data and diagnostic scores. The latter, although necessary and of fundamental support, to date, cannot replace the clinic. As our fathers taught us, the clin- ic remains Queen. References 1. Aboyans V, Boukhris M. Dissecting the epidemiology of aortic dissection. Eur Heart J Acute Cardiovasc Care 2021;10:710-1. 2. 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