An Investigation is Always Trending
Aortic dissection is a disease with a high mortality rate. It is defined as the passage of blood from a rupture in the intimal layer to the medial layer of the aortic lumen. Sildenafil, which is used in the treatment of erectile dysfunction, has a vasorelaxant effect on the aorta. The use of sildenafil triggers aortic dissection. We have reported a patient who had no medical history other than a diagnosis of hypertension, and whose autopsy revealed aortic dissection and post-mortem blood examination revealed sildenafil.
Aortic dissection is defi ned as the passage of blood from a rupture in the intimal layer to the medial layer in the aortic lumen. It is a life-threatening sudden onset condition that requires immediate diagnosis and treatment. Mortality rate is quite high despite the treatment. Dissection, especially in the ascending aorta, the mortality rate can be 25% in the fi rst 24 hours and 50% in the fi rst 48 hours from the onset of symptoms if left untreated [1,2].
Patients with aortic dissection oft en apply to the outpatient clinic with complaints of pain in the chest, neck, back or interscapular area . In addition, atypical complaints such as high blood pressure, anxiety, syncope, hemiplegia and dysphagia may also be encountered .
Sildenafi l used in the treatment of erectile dysfunction reduces aortic “stiff ness” in people. Studies have shown that sildenafi l has vasorelaxant eff ects on rat aorta. Due to this eff ect, it has been stated that sildenafi l use may trigger intimal rupture .
We aim to contribute to the literature with this study as the occurrence of aortic dissection following sildenafi l use is a very rare case as seen in the case of our patient whose autopsy showed aortic dissection and post-mortem blood examination showed sildenafi l in blood.
It was decided to carry out an autopsy as the death of a 63-year-old male patient was found suspicious. It was stated that the patient who did not have chronic diseases other than hypertension did not take his medication regularly. It has been reported that on the day of death the patient showed no apparent symptoms, the patient went to bed to sleep and his wife who went to join him after a period of time noticed a bruise on patient’s chest area and called 112 for an ambulance, however following the death of the patient despite all interventions in the ambulance, an autopsy has been carried out, and in the external examination of the chest, no other distinct conditions have been detected other than hyperaemic area which was thought to be due to previous medical intervention. Internal examination revealed cardiac tamponade when the pericardial incision was made. Aortic dissection was found in the ascending aorta and the dissection lumen was opened in the pericardium. Widespread calcifi ed atheroma plaques were found in the aorta. In the proximal part of the anterior descending branch of the left coronary artery, it was found that the lumen was slightly narrowed with calcifi ed atheroma plaques, and the lumen of the circumfl ex branch and right coronary artery were open. Both lungs were found to be hyperaemic and severely edematous.
Post-mortem toxicological analysis detected 45 ng/ml Sildenafi l, 310 ng/ml lidocaine and 22 ng/ml diclofenac in the blood.
Even though aortic dissection is a rare condition, delays in diagnosis or treatment result in high mortality rates . Chest pain was reported by more than 90% of the patients and sudden onset, tearing and disintegrating chest pain was reported by more than 80% of the dissected patients . In addition, there are studies reporting pain-free aortic dissection in 10-55% of the patients . Similarly, in our case, it was also reported that the patient did not describe any chest pain and aortic dissection did not present any symptoms other than not feeling well. Some researchers attributed the fact that some dissections are painless in the aorta to the lack of tension in the aortic wall in slowly developing dissections, while others attributed it to the preservation of the adventitia layer that conveys the sense of pain in the aorta. However, both of these opinions have not been fully explanatory . It has also been reported that altered pain perception due to cerebral hypoperfusion secondary to acute aortic dissection may make it diffi cult to identify pain .
In the Stanford classifi cation performed in aortic dissection, the dissection is divided into two according to the location of the dissection. Th e ascending aorta is classifi ed as Type A and the descending aorta is classifi ed as Type B. In the DeBakey classification, the entire aorta is included in Type I. Only the ascending aorta is included in Type II, and only the descending aorta is included in Type III . Our case with localized dissection of the ascending aorta is classified as Type A according to Stanford and Type II according to DeBakey.
Hypertension has been reported as a risk factor in 62-78% of the cases with acute aortic dissection. Connective tissue diseases such as atherosclerosis, Marfan syndrome and Ehler-Danlos syndrome, and chromosomal disorders such as aortic coarctation, bicuspid aortic valve, anuloaortic ectasia, aortic dilatation, aortic arthritis, archus aortic hypoplasia, Turner syndrome and Noonan syndrome have also been reported as other risk factors especially for pregnancy aortic dissection in the 3rd trimester [1,3,11]. It has also been reported that the patient who was diagnosed with hypertension did not use his hypertension medication regularly.
Chest radiography, transthoracic echocardiography, tomography, magnetic resonance imaging, and conventional angiography are the imaging methods used for the diagnosis of aortic dissection . Spiral CT has been reported to have a sensitivity of 83-100% and a specificity of 87-100% . The patient was diagnosed with aortic dissection during the autopsy as he was deceased before he could be taken to the hospital.
Sildenafil, a selective PDE 5 inhibitor and used in the treatment of erectile dysfunction, causes vasodilatation and increased smooth muscle relaxation with a nitric oxide / cyclic guanosine monophosphate (NO / cGMP) dependent effect, thus prolonging erection . Sildenafil, which has been reported to have vasorelaxant effects on aorta in in-vitro studies, reduces aortic stiffness in people . In another study conducted on pulmonary arteries, sildenafil has been reported to increase pulmonary flow and increase pulmonary smooth muscle cells without changing the pulmonary artery or systemic blood pressure. Considering all these reasons, it has been reported that the use of sildenafil, especially with an underlying pathology, may trigger dissection by making the aortic wall more sensitive .
It has been reported that the patient, who was diagnosed with systemic hypertension, which is one of the risk factors of aortic dissection, and whose post-mortem blood examination detected sildenafil in his blood, had erectile dysfunction complaints and was most probably using an aphrodisiac medication. Sildenafil, which is reported to have vasorelaxant effects on the aorta, is thought to have triggered dissection in the patient with underlying hypertension. Sildenafil is thought to be the causative agent for a very fatal disease such as aortic dissection. In this respect, it is thought that our case will make an important contribution to the literature.
Figure 1: Figure 1: Cardiac tamponade due to aortic dissection.
Figure 1: Figure 2: Dissection area in ascending aorta.