The Exchange

Commentary and Observations from
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<a href='/the-exchange/thoracic-aortic-aneurysm-part-2-'>Thoracic Aortic Aneurysm (Part 2)</a>

Thoracic Aortic Aneurysm (Part 2)

Thoracic aortic aneurysms (TAA) often expand slowly over time and usually without symptoms, making them difficult to detect. Some aneurysms never rupture. Many start small and stay small, although many expand over time. How quickly an aortic aneurysm may grow is difficult to predict. Only about 5% of patients experience symptoms before an acute event occurs, and for the other 95% the first “symptom” is often death.

As a TAA grows, some people notice these common symptoms:

  • Tenderness or pain in the chest
  • Back pain
  • Hoarseness
  • Cough
  • Shortness of breath
  • Wheezing

As noted above, a wide variety of signs and symptoms may be the presenting complaint in TAA. For example, TAA may exert pressure on upper airway structures causing hoarseness, cough, shortness of breath, or wheezing.

Chest pain is by far the most common presenting symptom, being present in 75% of patients. In 85% of patients, the pain is abrupt and severe. The classical description of “tearing pain” is only present for 51% of patients; most describe it as sharp or stabbing. However, 5% to 15% of patients get to the emergency department without any pain.

Other clinical presentations to be on the lookout for include hypertension (32%-49%), aortic regurgitation (32%-45%), pulse deficit or limb ischemia (15%-26%), syncope (9%-13%), shock and/or tamponade (8%-18%), hypotension without shock (8%-14%), heart failure—usually due to acute aortic regurgitation (6%), focal neurological deficits (5%-8%) and pericardial friction rub (2%). Even fever of unknown origin has been described as an initial presentation.

Individuals may also experience sudden loss of consciousness and signs of stroke, such as weakness and paralysis on one side of the body. Dysphagia is a common complaint of patients with thoracic disease, and often arises from obstruction of the upper digestive tract or extrinsic compression of the esophagus. Sometimes it is associated with neuromuscular disorders.

Thus, the symptoms of a TAA may look like a multitude of other conditions and advanced practice providers would do well to ALWAYS have TAA in the differential for any chest pain complaint. This entity is a commonly misdiagnosed condition, with an inevitable lawsuit afterwards, and is extremely hard to defend if not initially in the differential.

References
  • Centers for Disease Control and Prevention. WISQARS leading causes of death reports, 1999 - 2007. webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. Accessed August 28, 2019.
  • Elefteriades JA, Farkas EA. Thoracic aortic aneurysm clinically pertinent controversies and uncertainties. J Am Coll Cardiol. 2010;55:841-857.
  • Goldfinger JZ, Halperin JL, Marin ML, Stewart AS, Eagle KA, Fuster V. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol. 2014;64:1725-1739.
  • Hansen MS, Nogareda GJ, Hutchison SJ. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection. Am J Cardiol. 2007;99:852-856.

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