Medicine

A 52-year-old man develops sudden severe retrosternal chest pain that radiates to his back.

Within minutes, he became unconscious. He is a heavy smoker and has history of hypertension. Blood pressure 85/56 mmHg Heart rate 92 /min. Which of the following is the most likely diagnosis?

  1. A Vasovagal attacks
  2. B Pulmonary embolism
  3. C Tear in the aortic intima Correct answer
  4. D Acute myocardial infarction

Explanation

Core Concept: Acute Aortic Dissection (likely Type A involving the ascending aorta, given the rapid hemodynamic collapse, possibly from cardiac tamponade or aortic rupture).

Clinical Presentation:

  • Sudden, severe, 'tearing' or 'ripping' chest pain radiating to the back, followed by rapid hemodynamic instability (hypotension, shock, syncope). Risk factors include chronic hypertension and smoking.
  • Complications: Aortic rupture, cardiac tamponade, acute aortic regurgitation, stroke, and death.

Diagnosis:

  • First-line: Bedside echocardiography (to check for pericardial effusion/tamponade and aortic root dilation) or CT angiography of the chest if the patient is stable enough.
  • Gold standard: Transesophageal echocardiography (TEE) or CTA.

Management:

  • Acute: Immediate fluid resuscitation and emergent surgical repair. (Note: While BP control with IV beta-blockers is standard for hypertensive dissection, this patient is hypotensive/shocky, requiring immediate surgical intervention).

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