A 65-year-old man comes to the emergency department due to sudden-onset chest pain followed by syncope. The pain started an hour ago, during which he had an episode of syncope lasting 1-2 minutes. The patient has had no dyspnea or palpitations. He has never had similar symptoms before. Medical history is significant for hypertension and a 40-pack-year smoking history. Blood pressure is 190/110 mm Hg in both arms; pulse is 100/min and regular; and respirations are 24/min. Pulses are symmetric and equal in all extremities. Jugular venous pressure is normal. Breath sounds are normal on both sides. There is an S4 gallop. ECG shows changes consistent with left ventricular hypertrophy. Serum troponin is normal. D-dimer is elevated. Chest x-ray shows an enlarged cardiac silhouette but is otherwise unremarkable. CT scan of the chest is obtained and is shown below: Which of the following is the best next step in management of this patient?

Question

A 65-year-old man comes to the emergency department due to sudden-onset chest pain followed by syncope.  The pain started an hour ago, during which he had an episode of syncope lasting 1-2 minutes.  The patient has had no dyspnea or palpitations.  He has never had similar symptoms before.  Medical history is significant for hypertension and a 40-pack-year smoking history.  Blood pressure is 190/110 mm Hg in both arms; pulse is 100/min and regular; and respirations are 24/min.  Pulses are symmetric and equal in all extremities.  Jugular venous pressure is normal.  Breath sounds are normal on both sides.  There is an S4 gallop.  ECG shows changes consistent with left ventricular hypertrophy.  Serum troponin is normal.  D-dimer is elevated.  Chest x-ray shows an enlarged cardiac silhouette but is otherwise unremarkable.  CT scan of the chest is obtained and is shown below:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8a1_2903_bc81_eb7006c1d5a3_MD0003_00 This patient's presentation is consistent with an acute ascending aortic dissection, which is a surgical emergency. Aortic dissections are commonly classified based on ascending aorta involvement. Those that involve the ascending aorta are known as type A dissections, accounting for approximately 60%. Those originating in the descending aorta are known as type B dissections. Dissections can propagate proximally or distally; therefore, a type B dissection may extend to involve the ascending portion, becoming a retrograde type A dissection. classified The most common symptom of acute aortic dissection is sudden-onset chest or back pain that is typically severe, sharp, and tearing. Complications of type A dissections, including syncope, stroke, myocardial infarction, or heart failure, depend on the vessels and structures involved (eg, subclavian or carotid arteries, coronary artery ostia, aortic root). Additional signs may include asymmetry of upper extremity blood pressures, hypotension, and aortic regurgitation. D-dimer elevation (sensitive but not specific) is frequently seen due to the presence of fibrin degradation products. ECG findings depend on underlying comorbidities (eg, hypertension) and on whether the coronary ostia have been compromised. Plain radiographs may demonstrate a widened cardiac silhouette; CT angiography confirms the diagnosis, often revealing an intimal flap and double lumen. widened cardiac silhouette intimal flap Type A dissections have a very high mortality rate in the absence of immediate surgical intervention. Intraoperative transesophageal echocardiography is frequently performed to identify further abnormalities that may require intervention including aortic root/valve damage or tamponade. (Choices A and D) Early identification of aortic dissection is essential because therapies for similarly presenting conditions (eg, aspirin and heparin for myocardial infarction; thrombolytics for pulmonary embolism or ischemic stroke) worsen outcomes and are contraindicated. In this patient, the normal troponin, the lack of acute ECG changes, and the presence of imaging findings consistent with dissection make myocardial infarction and pulmonary embolism unlikely. (Choice B) Type B dissections that do not result in malperfusion to thoracic or abdominal organs (eg, mesenteric ischemia) may be managed medically with pain and blood pressure control. Type B dissections complicated by organ malperfusion benefit from urgent surgical or endovascular repair. (Choice E) Coronary angiography is a useful diagnostic measure in acute ST-elevation myocardial infarction, which would cause acute ECG changes and a troponin elevation. It does not have a role in type A aortic dissection because it delays definitive surgical management. Educational objective: Type A dissections involve the ascending aorta and present with sudden-onset chest or back pain that is severe and described as sharp or tearing. They may be complicated by syncope, stroke, myocardial infarction, or heart failure and require immediate surgical intervention. References: Acute aortic dissection and intramural hematoma: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27533160) Aneurysms of the ascending aorta. (http://www.ncbi.nlm.nih.gov/pubmed/22532815)

A 65-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset