A 54-year-old man comes to the emergency department with severe chest and neck pain that started 2 hours ago. His past medical history is significant for hypertension treated with amlodipine and irbesartan. His father died suddenly at the age of 43 years. He does not smoke or use illicit drugs.
His blood pressure is 162/100 mmHg and pulse is 101/min. He appears mildly uncomfortable due to pain.
EKG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and T wave inversions in leads V5 and V6. Chest x-ray findings are shown below.

He is initially treated with nitroglycerin.
What is the best next step in managing this patient?

Question

A 54-year-old man comes to the emergency department with severe chest and neck pain that started 2 hours ago.  His past medical history is significant for hypertension treated with amlodipine and irbesartan.  His father died suddenly at the age of 43 years.  He does not smoke or use illicit drugs.
His blood pressure is 162/100 mmHg and pulse is 101/min.  He appears mildly uncomfortable due to pain.
EKG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and T wave inversions in leads V5 and V6.  Chest x-ray findings are shown below.

He is initially treated with nitroglycerin.
What is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_95e5_4267_853d_f1279e046145_MD0002_00 This patient presents with hypertension, anterior chest pain and neck pain with widening of the mediastinum on chest x-ray suggestive of acute aortic dissection involving the ascending aorta. Descending aortic dissections present more frequently with back pain. Neck pain may suggest coronary artery ischemia due to occlusion by dissecting flap. This patient has T wave inversions which may suggest myocardial ischemia or could be secondary repolarization changes from left ventricular hypertrophy. Since anticoagulation is contraindicated in acute aortic dissection, the diagnosis needs to be excluded before treating with antiplatelet agents or anticoagulants (Choice A) for suspected myocardial ischemia. These agents may increase the risk of hemothorax and hemopericardium in aortic dissection. Ascending aortic dissection is considered a surgical emergency with reported mortality rate of 1 to 2% per hour after the onset of symptoms. Chest radiography has limited diagnostic sensitivity and specificity as patients with tortuous aorta may also have a widened mediastinum. Rapid confirmation can be obtained by chest CT angiogram (CTA). It has high sensitivity and specificity for identification of intimal flap. TEE is preferred in patients with renal insufficiency or contrast allergy. intimal flap (Choice B) There is no indication for urgent cardiac catheterization (no ST elevations or new left bundle branch block) in this case and it may further delay care. (Choice C) Chest tube insertion is indicated in patients with pneumothorax, hemothorax or large pleural effusions, which are readily identified on chest radiography. (Choice E) A repeat EKG and serial cardiac enzyme measurements would be appropriate once the possibility of aortic dissection has been definitively ruled out. Educational objective: Chest pain associated with hypertension and a widened mediastinum is suggestive of thoracic aortic dissection which has high mortality. Timely diagnosis with chest computed tomography angiogram is essential before treating other causes of chest pain. TEE is preferred in patients with renal insufficiency. __________ References: Diagnosis and management of acute aortic syndromes: dissection, intramural hematoma, and penetrating aortic ulcer penetrating aortic penetrating aortic ulcer. (http://www.ncbi.nlm.nih.gov/pubmed/25156302) The role of imaging in aortic dissection and related syndromes. (http://www.ncbi.nlm.nih.gov/pubmed/24742892)

A 54-Year-Old Man Comes to the Emergency Department with Severe