A 70-year-old man is brought to the emergency department due to 3 hours of intense, constant chest and neck pain that radiates to the interscapular area. The patient describes the pain as sharp. He has never experienced this type of pain before. His other medical problems include a 20-year history of hypertension and a 10-year history of type 2 diabetes mellitus. He does not use tobacco or alcohol. The patient appears anxious and uncomfortable. His blood pressure is 189/110 mm Hg in the right arm and 181/112 mm Hg in the left, pulse is 105/min, and respirations are 18/min. Examination shows an early decrescendo diastolic murmur best heard at the left sternal border of the fourth intercostal space. ECG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and T-wave inversions in leads V5 and V6. Serum creatinine is 2.1 mg/dL. Which of the following is the best next step in management of this patient?

Question

A 70-year-old man is brought to the emergency department due to 3 hours of intense, constant chest and neck pain that radiates to the interscapular area.  The patient describes the pain as sharp.  He has never experienced this type of pain before.  His other medical problems include a 20-year history of hypertension and a 10-year history of type 2 diabetes mellitus.  He does not use tobacco or alcohol.  The patient appears anxious and uncomfortable.  His blood pressure is 189/110 mm Hg in the right arm and 181/112 mm Hg in the left, pulse is 105/min, and respirations are 18/min.  Examination shows an early decrescendo diastolic murmur best heard at the left sternal border of the fourth intercostal space.  ECG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and T-wave inversions in leads V5 and V6.  Serum creatinine is 2.1 mg/dL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d176_bf9b_bc81_6fcb98d88874_MD0003_00 Acute type A (ascending) aortic dissection is the most likely diagnosis in this patient with sudden severe chest pain radiating to the back, significant hypertension, decrescendo diastolic murmur of aortic regurgitation (due to proximal extension of the dissection into the aortic valvular annulus), and elevated creatinine of 2.1 mg/dL (possibly due to distal extension into the renal arteries). Some patients with aortic dissection have a pulse deficit or differential blood pressure (>20 mm Hg difference) in the upper extremities; however, this finding is noted in only 20%-30% of the patients and its absence should not be used to exclude the diagnosis. Type A aortic dissections are surgical emergencies with mortality rates of 1%-2% per hour following symptom onset; therefore, rapid diagnosis and treatment is critical to reduce morbidity and mortality. The diagnosis is confirmed by imaging studies: Transesophageal echocardiography has excellent sensitivity and specificity and is the preferred diagnostic study in patients with renal insufficiency (such as this patient) or hemodynamic instability. CT angiography is the preferred diagnostic study in hemodynamically stable patients; however, it requires the use of iodinated contrast agents and should be avoided in patients with renal insufficiency. MR angiography is more time consuming and requires the administration of gadolinium-containing contrast agents for contrast enhancement; it should also be avoided in patients with moderate to severe kidney disease due to the risk of nephrogenic systemic fibrosis (Choice C). (Choices A and B) High-dose (not low-dose) aspirin and troponin levels should be considered in patients presenting with acute coronary syndrome. Coronary angiography is indicated in patients with high-risk acute coronary syndrome (unstable angina, non-ST elevation or ST elevation myocardial infarction). This patient's ECG findings of T-wave inversions in leads V5 and V6 are likely due to left ventricular hypertrophy with secondary repolarization changes, and his overall presentation is suggestive of acute aortic dissection. Antiplatelet or anticoagulant therapy can increase the bleeding complications associated with aortic dissection (eg, hemothorax, hemopericardium, propagation of dissection). (Choice D) In patients presenting with dyspnea, serum B-type natriuretic peptide (BNP) levels are occasionally obtained to differentiate between cardiogenic pulmonary edema (associated with elevated BNP levels) and noncardiac causes of dyspnea. BNP measurement has no role in the evaluation of patients with suspected acute aortic dissection. Educational objective: Transesophageal echocardiogram has excellent sensitivity and specificity for the diagnosis of aortic dissection and is the preferred diagnostic study in patients with hemodynamic instability or renal insufficiency. CT angiography and MR angiography should be avoided in patients with moderate to severe kidney disease. References: Screening, evaluation, and early management of acute aortic dissection in the ED. (http://www.ncbi.nlm.nih.gov/pubmed/22708909) Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. (http://www.ncbi.nlm.nih.gov/pubmed/26129948)

A 70-Year-Old Man Is Brought to the Emergency Department Due