Item ~?Mark <?

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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 189/11 0 mm Hg in the right arm and
181/11 2 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 right 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?

o A. Coronary angiography
0 B. Low-dose aspirin and troponin I levels
o C. MR imaging
o D. Serum B-type natriuretic peptide levels
o E. Transesophageal echocardiography

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Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
0. ld : 3956 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

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
181/11 2 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 right 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?

A Coronary angiography [9%]

B. Low-dose aspirin and troponin I levels [27%]
C. MR imaging [1 2%]
D. Serum 8-type natriuretic peptide levels [1%]
., :J E. Transesophageal echocardiography [51%]

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Explanation : User ld

Diagnostic approach for suspected aortic dissection

Suspect ed aortic d issect ion

• Risk fact ors (eg, Marfan syndrome, connective tissue
disease, hypertension)
• Tearing chest/abdominal pain rad iating to the back
• Perfusion deficit s (eg, pulse deficit,>20 mm Hg
blood pressure difference bet ween right & left arm,
aort ic regurgitation murmur)

Chest x-ray or ECG Yes Evaluate &

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Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
0. ld : 3956 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

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Explanation: User ld

Diagnostic approach for suspected aortic dissection

Suspected aortic dissection

• Risk factors (eg, Marfan syndrome, connective tissue
disease, hypertension)
• Tearing chest/abdominal pain radiating to the back
• Perfusion deficits (eg, pulse deficit,> 20 mm Hg
blood pressure difference between right & left arm,
aortic regurgitation murmur}

Chest x-ray or ECG Yes Evaluate &

suggesting other diagnoses? treat appropriately

No

Normal serum creatinine

& no contrast allergy

No Yes

I TEE preferred Imaging based on availability

• TEE
• Chest CT with contrast
• MRI (only if nonemergency
& patient can lie still)
©UWorld

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

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© UWorld

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 noninvasive imaging:
• 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).

(Choice A) 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 ofT-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.

(Choice B) Antiplatelet therapy (eg, aspirin) and troponin levels should be considered in
patients presenting with acute coronary syndrome. Antiplatelet or anticoagulant therapy
can increase the bleeding complications associated with aortic dissection (eg,
hemothorax, hemopericardium, propagation of dissection).

(Choice 0) 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.
 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).

(Choice A) 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 ofT -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.

(Choice B) Antiplatelet therapy (eg, aspirin) and troponin levels should be considered in
patients presenting with acute coronary syndrome. 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 8-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 sensit ivity and specificity for the
diagnosis of aortic dissection and is the preferred diagnostic study in patients with
hemodyn amic instability or renal insufficiency. CT angiography and MR angiography
should be avoided in patients with moderate to severe kidney disease.

References:
1. Screening, evaluation, and early management of acute aortic dissection
in the ED.
2. Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of
aortic diseases.

Time Spent: 2 seconds Copyright © UWorld Last updated: [07/27/2016]