Unusual Case of Spontaneous Postcoital Type A Aortic Dissection

Abstract

Aortic dissection is a life-threatening condition that may present as severe acute chest or abdominal pain, especially in high-risk patients, and should raise a high index of suspicion for aortic dissection when occurring after moderate-to-high-intensity activities, such as sexual intercourse. Sexual intercourse leads to physiological stress on the body causing an abrupt elevation in blood pressure and shearing force against the vessel wall. This shearing force increases the risk of vessel wall dissection. Below, we discuss a rare case of type A aortic dissection after sexual intercourse and highly recommend physicians to evaluate and educate their high-risk patients regarding aortic dissection with such activities.

INTRODUCTION

Aortic dissection is a serious medical condition characterized by separation of the aortic wall layers by extraluminal blood flow through a luminal tear.[1] Although hypertension remains the most important risk factor for aortic dissection,[2] few cases were reported in the literature about aortic dissection after vigorous sexual intercourse.[1] Sexual intercourse should be viewed as a dynamic exercise where the blood pressure can suddenly rise and lead to serious complications in high-risk patients.

Herein, we report an extremely rare case of a man presenting with type A aortic dissection after multiple occurrences of sexual intercourse within a 24-h period.

CASE PRESENTATION

A 41-year-old African-American man with a past medical history of well-controlled hypertension (compliant with his medications) presented to the emergency room with the chief complaint of substernal chest pain. He reported a sudden onset of right-sided groin pain radiating to his scrotum, followed by chest pain during sexual intercourse. The patient described his chest pain as sharp in nature, radiating to the back, with a severity of 10/10. He stated the symptoms began during his fourth occurrence of sexual intercourse that day. He is compliant with his home medication of nifedipine 30 mg daily.

On presentation, he was tachycardic with a heart rate of 120/min and his blood pressure was 150/90 mmHg. The patient was conscious, alert, and oriented to person, place, and time. He was diaphoretic, but his physical examination was otherwise unremarkable. Laboratory studies revealed a potassium level of 3.3 mmol/L (normal: 3.5–5.3 mmol/L). Other laboratory results were within normal limits. Electrocardiograph revealed sinus rhythm, with no ST elevation or other signs of ischemia. Chest X-ray revealed no signs of acute cardiopulmonary pathology. Computed tomography (CT) angiogram of the chest and abdomen revealed a Stanford type A (DeBakey type 1) aortic dissection involving the proximal aortic root, the major vessels emerging from the aortic arch and the proximal iliac artery bilaterally [Figures 1–3]. The true lumen supplies the celiac trunk, the superior mesenteric artery, and renal arteries. The false lumen supplies the inferior mesenteric arteries. There is a fusiform dilation of the abdominal aorta below the level of the renal arteries measuring 3.4 cm × 3.2 cm.

Figure 1.

Computed tomography angiography demonstrates ascending and descending thoracic aortic dissection

Figure 3.

Computed tomography angiography sagittal section demonstrates thoracic and abdominal aorta dissection

Figure 2.

Computed tomography angiography demonstrates abdominal aorta dissection

The patient was started on labetalol drip for stringent blood pressure control, with a goal mean arterial pressure of 65–70 mmHg. He was also started on morphine and lorazepam for pain control. An arterial line was placed for close monitoring of his blood pressure, and he was admitted to the cardiac intensive care unit (CICU). Bedside echocardiogram was done in the CICU which revealed a severely reduced left ventricular ejection fraction of 15%–20% with severe global hypokinesia. No signs of cardiac tamponade were appreciated [Figure 4]. Due to the severity of the disease and the findings on echocardiogram, the patient was transferred to an outside facility for aortic dissection repair.

Figure 4.

Echo shows thoracic aortic dissection (red arrow)

DISCUSSION

Aortic dissection is defined as a medial layer intimal tear commonly occurring in the right lateral wall of the ascending aorta due to its exposure to the highest shearing force.[3] This separation of the vessel wall produces a false lumen that can progress to full aortic rupture or push back toward the true lumen making another intimal tear.[4]

In the general population, the incidence of aortic dissection ranges from 2.6 to 3.5 per 100,000 person yearly.[2,3] Clinical signs and symptoms of aortic dissection commonly occur during the daytime.[5,6] The most reported symptom of type A dissection is anterior chest pain and in type B is back pain.[5,6] Other common signs such as impaired pulse or even absent pulse; can be seen in the carotid, femoral or brachial artery with or without a variation in systolic blood pressure.[7] It is also important to note, new onset of heart murmurs. Hypotension, acute heart failure, and focal neurological deficits can also be seen in aortic dissection.[4,8]

Aortic dissection is classified according to the time of onset and the anatomical area of involvement. The Stanford and DeBakey systems both categorize by area of involvement. The Stanford system is divided into type A involving the ascending aorta and type B involving only the descending aorta.[7] DeBakey is another system of classifying and organizing aortic dissection into three main types. Type I affects the ascending and all other segments of the aorta, type II is confined to the ascending aorta, and type III involves only the descending part of the aorta.[8] The classification of aortic dissection based on the time of onset is broken down into acute (1 week), subacute (1 week to 1 month), and chronic (more than 1 month).[9]

Risk factors for aortic dissection include age, male sex, hypertension, atherosclerosis, collagen vascular disease (such as Marfan syndrome), bicuspid aortic valve, prior aortic valve replacement surgery, and autoimmune inflammatory disease.[9,10] Of the above risk factors, hypertension is considered the most important predisposing factor with an incidence of 80%. Other causes of severe, sudden elevation in blood pressure are related to substances such as cocaine, energy drinks, and ergotamine. Various high-intensity training and weightlifting have also been reported as a cause of dissection.[11,12]

Through the literature review, we found that blood pressure and heart rate monitored in healthy individuals during different phases of sexual intercourse lead to mild-to-moderate changes in these variables.[12] The peak change in blood pressure and heart rate was seen at the beginning of arousal and dropped 10 min after orgasm.[12]

Sexual intercourse is considered an emotional and physical stressor leading to increased cardiovascular demand and risk of aortic dissection in males.[13,14]

Diagnosis of this devastating and life-threatening condition requires a high index of suspicion along with imaging modalities necessary to rapidly identify the condition and facilitate the conduction of early treatment. Among these imaging studies, transesophageal echocardiogram is the preferred imaging modality in hemodynamically unstable patients as it allows for quick evaluation with a sensitivity approaching 98% and specificity of 63%.[13] In hemodynamically stable patients, it is recommended to use a more specific modality of imaging such as CT angiography or gadolinium-enhanced magnetic resonance angiography, which can diagnose aortic dissection with a specificity of 95%–100%.[14]

Aortic dissection type A is considered as a surgical emergency due to the high risk of life-threatening complications including cardiac tamponade, myocardial infarction, stroke, and rupture with an exponential increase in mortality without intervention.[7] The most common surgical approach includes an invasive open removal of the intimal tear and obliteration of the track into the false lumen along with repair or placement of aortic valve.[15] Another approach is endovascular with stent grafting.[16] In contrast, type B aortic dissection is managed medically in most cases and surgery is only needed if complicated by organ malperfusion syndrome or extension of the dissection.[5,6,17]

CONCLUSION

Aortic dissection, especially type A, is a life-threatening condition that requires emergent treatment. Although hypertension remains the most pertinent risk factor for aortic dissection, vigorous exercise including sexual intercourse can dramatically increase the blood pressure and heart rate putting patients at high risk for aortic dissection.

In the case above, we discussed a rare type A aortic dissection in a patient with hypertension who presented with severe aortic dissection and extensive involvement of the aorta. The combination of physical and emotional stress on the body from sexual intercourse provides an increased risk for aortic dissection and can potentially increase the blood pressure with vigorous or prolonged sexual activity.

The topic of sexual activity and physiological stress is not well described in the literature, and not enough information is available to the general population. Many patients do not consider sexual activity as straining and therefore are not viewing sexual intercourse as a potential risk to their health. Hopefully, this case report can increase awareness of aortic dissection seen with sexual activity and encourage physicians to educate their patients on these risks.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.