Painless Aortic Dissection Associated with Tyrosine Kinase Inhibitor Therapy

IF 1.2 4区 医学 Q3 EMERGENCY MEDICINE
Huda Fatima MD, Kalen Jacobson MD
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引用次数: 0

Abstract

History of presentation

A 69-year-old male presented to the ED with a thoraco-abdominal aortic dissection (AD) (DeBakey type IIIB/Stanford classification B) and an intramural thoracic wall hematoma, detected during CT imaging. He arrived with hypertension (BP 160/92, heart rate 81) but was asymptomatic. Physical examination revealed palpable pulses.

Past medical history

Stage IV anorectal mucosal melanoma treated with ipilimumab/nivolumab, nivolumab+axitinib, radiation, currently on nivolumab+relatlimab. Prior superior mesenteric and right external artery dissection, right common iliac artery aneurysm, central adrenal insufficiency, hypothyroidism and recent hypertension-related syncopal episodes, leading to discontinuation of Losartan.

Investigations

Lab work was normal, EKG showed normal sinus rhythm. Echocardiogram was normal with ejection fraction 60-65%.

Management

The patient received IV labetalol and esmolol, following which BP improved. CT indicated chronicity with proximal thrombosis, and surgical intervention was not recommended. Cardiology started coreg 3.125 mg twice daily and a low-dose statin. He was discharged with oral anti-hypertensive meds for outpatient follow-up.

Causes

Hypertension, aging, atherosclerosis, connective tissue diseases like Marfan and Ehlers-Danlos syndromes, hereditary factors like Turner syndrome and bicuspid aortic valve, coarctation of the aorta, previous cardiac surgery, smoking, cocaine use, and iatrogenic factors such as VEGFR and TK inhibitors.

Mechanism of action

AD results from arterial wall tearing, causing a false lumen due to blood leakage through aortic media [2]. Stress or degeneration factors contribute [2]. Axatinib, a tyrosine kinase inhibitor blocking the TK activities of VEGFR, can lead to hypertension and cardiac dysfunction linked to AD [3]. It's unclear if AD-related hypertension is due to axatinib, suggesting tyrosine kinase inhibitors may directly contribute to AD.

与酪氨酸激酶抑制剂疗法相关的无痛主动脉夹层
病史一名 69 岁的男性因胸腹主动脉夹层 (AD)(DeBakey IIIB 型/斯坦福分级 B)和胸壁内血肿(CT 成像中发现)来到急诊室。来时他患有高血压(血压 160/92,心率 81),但没有任何症状。既往病史IV期肛门直肠粘膜黑色素瘤,接受过ipilimumab/nivolumab、nivolumab+axitinib和放射治疗,目前正在接受nivolumab+relatlimab治疗。曾患肠系膜上动脉和右外侧动脉夹层、右髂总动脉瘤、中枢性肾上腺功能不全、甲状腺功能减退症以及近期高血压相关晕厥发作,因此停用了洛沙坦。患者接受了静脉注射拉贝洛尔和艾司洛尔,随后血压有所改善。CT 显示慢性近端血栓形成,不建议手术治疗。心内科开始给他服用 coreg 3.125 毫克,每天两次,以及低剂量他汀类药物。病因高血压、衰老、动脉粥样硬化、结缔组织疾病(如马凡综合征和埃勒斯-丹洛斯综合征)、遗传因素(如特纳综合征和主动脉双瓣、主动脉瓣狭窄)、既往心脏手术、吸烟、吸食可卡因以及先天性因素(如血管内皮生长因子受体和 TK 抑制剂)。主动脉瓣狭窄的作用机制是动脉壁撕裂,血液通过主动脉介质渗漏造成假腔[2]。应力或变性因素也是原因之一[2]。阿沙替尼是一种阻断血管内皮生长因子受体 TK 活性的酪氨酸激酶抑制剂,可导致与 AD 相关的高血压和心功能障碍 [3]。目前尚不清楚与AD相关的高血压是否由阿沙替尼引起,这表明酪氨酸激酶抑制剂可能直接导致AD。
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来源期刊
Journal of Emergency Medicine
Journal of Emergency Medicine 医学-急救医学
CiteScore
2.40
自引率
6.70%
发文量
339
审稿时长
2-4 weeks
期刊介绍: The Journal of Emergency Medicine is an international, peer-reviewed publication featuring original contributions of interest to both the academic and practicing emergency physician. JEM, published monthly, contains research papers and clinical studies as well as articles focusing on the training of emergency physicians and on the practice of emergency medicine. The Journal features the following sections: • Original Contributions • Clinical Communications: Pediatric, Adult, OB/GYN • Selected Topics: Toxicology, Prehospital Care, The Difficult Airway, Aeromedical Emergencies, Disaster Medicine, Cardiology Commentary, Emergency Radiology, Critical Care, Sports Medicine, Wound Care • Techniques and Procedures • Technical Tips • Clinical Laboratory in Emergency Medicine • Pharmacology in Emergency Medicine • Case Presentations of the Harvard Emergency Medicine Residency • Visual Diagnosis in Emergency Medicine • Medical Classics • Emergency Forum • Editorial(s) • Letters to the Editor • Education • Administration of Emergency Medicine • International Emergency Medicine • Computers in Emergency Medicine • Violence: Recognition, Management, and Prevention • Ethics • Humanities and Medicine • American Academy of Emergency Medicine • AAEM Medical Student Forum • Book and Other Media Reviews • Calendar of Events • Abstracts • Trauma Reports • Ultrasound in Emergency Medicine
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