Penetrating atherosclerotic ulcer (PAU), an uncommon etiology of acute aortic syndrome (AAS), is a potential cause of chest pain seen in emergency departments. As PAU may lead to electrocardiogram (ECG) changes or rarely, elevated troponin levels, it is most likely misdiagnosed as acute coronary syndrome (ACS). Hence, individuals with PAU may be offered potentially life-threatening treatment. This paper reports a case of a 81-year-old male who presented with intermittent chest pain with a history of old inferior myocardial infarction and stent placement in the left circumflex coronary artery (LCX) three years ago. Initially, he was diagnosed with non-ST-elevation myocardial infarction (NSTEMI) based on abnormal ECG changes and raised troponin I. However, emergency coronary angiography (CAG) showed no restenosis in the left circumflex coronary artery (LCX) but with mild stenosis in the left anterior descending artery (LAD) and right coronary artery (RCA). Computed tomographic angiography (CTA) of the whole aorta showed multiple atherosclerotic plaques with penetrating atherosclerotic ulcer in the aortic arch and descending aorta. Endovascular aortic repair with Ankura II covered stent was performed. This case study reminds us that it is clinically difficult to distinguish PAU from ACS. Upon excluding ACS from the diagnosis, we should take into consideration of PAU, especially in elderly patients with positive cTnI.
Shennan T, 1934, Dissecting Aneurysms, Medical Research Council, Special Report Series, No. 193, His Majesty’s Stationery Office, London.
Stanson AW, Kazmier FJ, Hollier LH, et al., 1986, Penetrating Atherosclerotic Ulcers of the Thoracic Aorta: Natural History and Clinicopathologic Correlations. Annals of Vascular Surgery, 1(1): 15-23.
Thygesen K, Alpert JS, Jaffe AS, et al., 2018, Fourth Universal Definition of Myocardial Infarction (2018). European Heart Journal, 40(3): 237-269.
Eggebrecht H, Plicht B, Kahlert P, et al., 2009, Intramural Hematoma and Penetrating Ulcers: Indications to Endovascular Treatment. European Journal of Vascular & Endovascular Surgery, 38(6): 659-665.
Vagnarelli F, Corsini A, Bugani G, et al., 2015, Troponin T Elevation in Acute Aortic Syndromes: Frequency and Impact on Diagnostic Delay and Misdiagnosis. European Heart Journal: Acute Cardiovascular Care, 5(7): 61-71.
Bischoff MS, Geisbusch P, Peters AS, et al., 2011, Penetrating Aortic Ulcer: Defining Risks and Therapeutic Strategies. Herz, 36(6): 498.
Coady MA, Rizzo JA, Elefteriades JA, 1999, Pathologic Variants of Thoracic Aortic Dissections. Cardiology Clinics, 17(4): 637-657.
Cho KR, Stanson AW, Potter DD, et al., 2004, Penetrating Atherosclerotic Ulcer of the Descending Thoracic Aorta and Arch. J Thorac Cardiovasc Surg, 127(5): 1393-1401.
Troxler M, Mavor AI, Homervanniasinkam S, et al., 2001, Penetrating Atherosclerotic Ulcers of the Aorta. British Journal of Surgery, 88(9): 1169-1177.
Erbel R, Aboyans V, Boileau C, et al., 2014, 2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases. European Heart Journal, 72(12): 1169-1252.