A 22 year old African immigrant female student who is otherwise well and fit was incidentally found to have an elevated blood pressure during a physical examination for evaluation of headache. She denied frequent use of over the counter medication, intravenous drug or recreation drug use. There is no family history of HTN, diabetes, coronary artery disease, sudden cardiac death, polycystic kidney disease or other polyglandular autoimmune endocrine disease. On initial examination blood pressure was 190/90 mm Hg in both upper extremities. On fundoscopic examination there was no papilledema; the rest of the examination was otherwise unremarkable. ECG and C-x-ray was essentially unremarkable. A cardiology consultation was placed; on reassessment, there was ejection click over aortic area, a continuous harsh murmur over interscapular space and radio-femoral delay of the pulse. Doppler echocardiography showed a bicuspid aortic valve with mild aortic regurgitation. Head CT was negative for aneurysm or bleeding. Careful review of the frontal chest radiographs revealed rib notching along the inferior aspect of the third to the eighth ribs. Diagnosis of aortic coarctation was suspected and a spiral CT of the thoracic aorta with three-dimensional reconstruction confirmed postductal coarctation. A cardiothoracic surgery consultation was obtained and the patient underwent successful repair. Coarctation of the aorta is an acyanotic congenital heart disease. Most patients are identified accidentally during routine medical examination. Coarctation accounts for approximately 5% of all congenital heart diseases. Coarctation is a discrete infolding of the posteriolateral wall of the aorta, which results in an obstructing membrane at the level of the ductus arteriosus. There are several classifications of the coarctation; it is most commonly classified into adult (postductal) type and infantile (preductal) type. However, many patients with preductal lesions do not present until adulthood. The age of the patient at presentation is dependent on the severity rather than the site of obstruction. Usually those with severe obstruction or associated cardiac anomalies present early, as a result of cardiac failure or occasionally cerebrovascular accident, aortic dissection, or endocarditis. 25-50% of patients will also have a bicuspid aortic valve. Patent ductus arteriosus, ventricular septal defects and Turner syndrome are other common associations with aortic coarctation. This case emphasizes the importance of a careful history and physical examination, which remain the cornerstones of diagnosis of coarctation.
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