Abdominal mask of acute coronary syndrome or ...? The expediency of including abdominal aorta screening in routine echocardiography

Abstract

An 86-year-old woman with a history of hypertension, paroxysmal atrial fibrillation, chronic kidney disease, type 2 diabetes and hypothyroidism, was admitted due to weakness and atypical chest pain accompanied by dyspnoea, abdominal pain, vomiting and lack of appetite. Also, a month ago the patient underwent left lower limb erysipelas and reported a 10 kg decrease in body weight over the past year. On admission, the patient was hemodynamically stable. Electrocardiography revealed sinus rhythm, first-degree atrioventricular block, and persistent ST-segment depression in the anterolateral loads. Biochemical tests revealed elevated high-sensitivity troponin level and high N-terminal pro-B-type natriuretic peptide concentration. Echocardiography showed normal left ventricle systolic function, ejection fraction of 50%, without evidence of significant valvular heart disease. Taking into consideration all of the above, the diagnosis of the acute coronary syndrome was proposed. Due to the standards applied in our echocardiography protocol (screening of abdominal aorta dimension in people over 65-years-old), a significant widening of the abdominal aorta was found. In computed tomography angiogram, abdominal 57 mm aortic aneurysm with a haemorrhagic thrombus and right iliac aneurysm with a large thrombus with deep ulceration were confirmed. The whole clinical picture suggests that the patien’s complaints resulted from the presence of large abdominal aortic and common iliac artery aneurysms, accompanied by pressure on the adjacent abdominal organs and with a high risk of sudden rupture. The described case confirms the validity of supplementing routine echocardiographic protocol with a screening assessment of the abdominal aorta, following European Society of Cardiology guidelines. Accurate diagnosis, in this case, protected the patient from acute coronary syndrome invasive treatment, which could result in intensive anticoagulant and antiplatelet therapy implementation and lead to life-threatening complications.