A 70-year-old man is brought to the emergency department due to intense, constant chest pain radiating to the neck and interscapular area. The patient has had the pain for the past hour and describes it as sharp. He has never experienced this type of pain before. Medical history includes hypertension, type 2 diabetes mellitus, and chronic kidney disease. He does not use tobacco or alcohol. Blood pressure is 78/56 mm Hg, pulse is 120/min, and respirations are 22/min. BMI is 32 kg/m2. On physical examination, the patient appears anxious, diaphoretic, and uncomfortable. There is an early decrescendo diastolic murmur best heard at the upper sternal area with an undisplaced cardiac apex. ECG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and T-wave inversions in leads V5 and V6. Serum creatinine is 1.8 mg/dL. Serum troponin I level is normal. In addition to adequate resuscitation, which of the following is the best next step in management of this patient?
Acute aortic dissection | |
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*Hypotension on presentation suggests aortic rupture or other complication (eg, cardiac tamponade, acute aortic regurgitation). SBP = systolic blood pressure; TEE = transesophageal echocardiography. | |
This patient's sharp and intense chest pain radiating to the neck and upper back is concerning for acute aortic dissection. Most patients are hypertensive on presentation; hypotension, as in this patient, suggests aortic rupture or another complication. The early decrescendo diastolic murmur at the left upper sternal border combined with a nondisplaced point of maximal impulse (ie, nondilated left ventricle) is consistent with acute aortic regurgitation (AR), which can result from extension into the aortic annulus and lead to cardiogenic shock.
Type A (ascending) aortic dissection necessitates emergency surgical repair. However, imaging must first be performed to confirm the diagnosis and characterize the location of the dissection plane. CT angiography of the chest (CT aortography) is often the test of choice, but hypotensive patients are at risk of imminent cardiac arrest and cannot safely undergo prolonged imaging. For these patients, transesophageal echocardiography (TEE), often performed in the operating room while preparing for emergency surgery, is usually preferred. TEE allows for visualization of the dissection plane and confirms type A aortic dissection.
(Choice A) Aspirin and serial troponin measurements are obtained for suspected acute coronary syndrome (ACS), which can cause chest pain, ECG changes, or troponin elevation (not always present initially). However, sharp pain radiating to the upper back (not consistent with ACS) should raise suspicion for dissection; V5 and V6 T-wave inversions can reflect left ventricular hypertrophy with secondary repolarization changes; and ACS can cause acute mitral regurgitation (eg, papillary muscle dysfunction) but not acute AR. Finally, aspirin and serial troponin measurements only are inappropriate for a patient with likely cardiogenic shock.
(Choice B) Emergency coronary angiography is indicated for ST-segment elevation myocardial infarction (STEMI), not seen on this patient's ECG, or non-STEMI with persistent hemodynamic instability. This patient's symptoms are more consistent with aortic dissection than ACS.
(Choice C) MR angiography of the chest (MR aortography) is occasionally used to evaluate aortic dissection, but it is even more time consuming than CT aortography and is not appropriate in an emergently hypotensive patient.
(Choice E) Ventilation-perfusion scan is used in patients with suspected pulmonary embolism who have a relative contraindication to CT pulmonary angiography (eg, renal dysfunction). Pulmonary embolism would not explain acute AR.
Educational objective:
In emergently hypotensive patients with suspected type A acute aortic dissection, transesophageal echocardiography is often the preferred imaging modality because it is diagnostically accurate and can be performed more quickly than CT or MR aortography.