Discussion
In this report, we described a 46 year old woman with past medical history of stage 1 hypertension which was under control, hyperlipidemia and recent COVID-19 whom represented with acute chest pain and cold sweat. The patient reported no traumatic events and no history of connective tissue disorders. Her clinical examination showed unequal radial pulses and a blood pressure difference between arms. During patient’s hospitalization, her blood pressure was within the normal range. The laboratory tests showed elevated D-dimer, troponin, ESR and CRP. The diagnosis and management of aortic dissection in early stages is of importance since it has numeric manifestations and can mimic other life threatening events such as myocardial infarction and pulmonary embolism 7. Silvestri et al., reviewed seventeen cases of aortic pathology in patients with clinically suspected or PCR confirmed COVID-19 and also reported hypertension as the most frequent comorbidity; they suggested a potential link between COVID-19 and aortic dissection 8.
There are some potential mechanisms for arterial pathology in COVID-19 patients. SARS-CoV-2 has spike proteins on its surface that binds a receptor which is expressed in the endothelium called angiotensin converting enzyme 2 (ACE-2). This means that SARS-CoV-2 can injure vascular endothelium in the body 9. SARS-CoV-2 downregulates ACE-2 which leads to over activation of classical renin-angiotensin system (RAS) and vasoconstriction10. ACE Inhibitor (ACEI) and angiotensin receptor blocking (ARB) drugs, which are used commonly for hypertension as in our patient, upregulate ACE-2 expression that can potentially increase the vascular entry of and injury by SARS-CoV-2. On the other hand, upregulation of ACE-2 can have vasodilatory and anti-inflammatory effects as a result of conversion of angiotensin II to angiotensin 1-711. However, in a study of 1128 hospitalized patients with COVID-19, those who took ACEI/ARB drugs had a lower all-cause mortality than those who didn’t take 12.
Another possible cause of arterial dissection in COVID-19 patients can be cytokine storm and inflammatory responses which leads to endothelial dysfunction 13. Inflammation may cause rupture of atherosclerotic plaque which can lead to dissection14. Studies have shown that the number of patients with aortic dissection were increased during the influenza season15, 16. Akgul et al., presented an aortic dissection in a COVID-19 patient which during the aortomy, they noticed significant aorta wall thickening as seen in inflammatory aortic pathologies17. Their finding is consistent with the potential association of inflammation caused by SARS-CoV-2 with aortic dissection.
As it has been suggested before, SARS-CoV-2 is a virus that causes multi-organ diseases and can manifests as life-threatening events10. Therefore, it is important to evaluate the association between COVID-19 and aortic dissection and the pathophysiology of it. Further studies are needed to establish this association.