Radiating Chest Pain

Try out this cardiology case and test your clinical knowledge. The answers are at the bottom.

Questions

A 54-year-old man presents to A&E with a severe pain in his chest. He reports that the pain is around an 8/10 and radiates to the back and began 2 hours ago. He looks pale and is very disorientated as to his surroundings.

Observations:
SpO2: 89%
Temperature: 37.1
BP: 87/48
HR: 120
RR: 27

Examination:

Mid diastolic murmur that is accentuated by leaning forward in expiration

 Q1: How would you manage this patient’s initial presentation?

The patient is stabilized and further imaging is requested, as shown below:

 

Q2: Comment on the CT – what is the diagnosis?

Image 1 – Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 8886https://radiopaedia.org/cases/aortic-dissection-stanford-a-3?lang=gb

Q3: What are the risk factors for this condition?

 

Q4: What is the definitive management for this condition?

Answers

Reveal the Answers

Answer to Question 1

This patient is hemodynamically unstable so an A-E approach should be adopted, with particular emphasis on the circulation part (i.e. ECG, IV fluid boluses, group & save + crossmatch bloods and early involvement of ITU for inotropic support etc..). In parallel, it is possible that the shock is secondary to a haemmorhage, thus the major haemmorhage protocol should also be activated and the blood bank and haematology lab informed of any additional blood products that may be required

Answer to Question 2

This is an axial CT Angiogram showing an aortic dissection in the ascending aorta (the false lumen is the darker coloured half of the ‘tennis ball’ which has less contrast than the true lumen)

Answer to Question 3

Important risk factors include:

• Connective tissue disease that causes aortic root dilation e.g. Marfan’s, Ehler-Danlos
• Mycotic e.g. syphilis, infective endocarditis
• Cocaine use
• MI/STEMI
• Hypertension

Answer to Question 4

The definitive management for this type (Stanford A – proximal to L common carotid) dissection is surgical correction e.g. with a Dacron graft and management of any blood pressure spikes with labetalol. The aortic regurgitation (diastolic murmur) will also likely require a valve replacement if significant LV dysfunction is demonstrated on echocardiography.

To get more information about the conditions mentioned in this case including diagnosis and management, have a look at our free haematology notes on In2Med. Written by medical students, we have pitched them just at the right level to help you ace your exams.

Dr Amol Joshi
University of Cambridge

About The Author

This case is written by Dr Amol Joshi who has an interest in writing medical puzzles.