Sudden chest pain, SOB, cold peripheries (418/1700)

A 50yo lady presents to ED with sudden severe chest pain radiating to both shoulder and
accompanying SOB. Exam: cold peripheries and paraparesis. What is the single most appropriate
dx?

a. MI
b. Aortic dissection
c. Pulmonary embolism
d. Good pastures syndrome
e. Motor neuron disease
































answer: B

Aortic Dissection
Tear in aortic intima allowing blood to dissect into the media

Etiology
• most common: HTN > degenerative/cystic changes > damage to aortic media
• other: connective tissue disease (e.g. Marfan’s, Ehlers-Danlos), cystic medial necrosis, atherosclerosis, congenital conditions (e.g. coarctation of aorta, bicuspid aortic valves, patent ductus arteriosus), infection (e.g. syphilis), trauma, arteritis (e.g. Takayasu’s)

Clinical Features
• sudden onset tearing chest pain that radiates to back with:

• HTN (75-85% of patients)
• Asymmetric BPs and pulses between arms (>30 mmHg difference indicates poor prognosis).
• Ischemic syndromes due to occlusion of aortic branches: coronary (MI), carotids (ischemic stroke, Horner’s syndrome), splanchnic (mesenteric ischemia), renal (AKI), peripheral (ischemic leg), intercostal vessels (spinal cord ischemia)
• “Unseating” of aortic valve cusps (new diastolic murmur in 20-30%) in Type A dissection
• Rupture into pleura (dyspnea, hemoptysis) or peritoneum (hypotension, shock) or pericardium (cardiac tamponade)
• Syncope

Investigations of Choice
• CT (gold standard) aortography, MRA: 100% sensitive and specific