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A 62-year-old man comes to the emergency department with sudden severe chest pain that began 30 minutes ago while lifting a box. The pain is tearing and radiates to the back. Blood pressure is 184/96 mm Hg in the right arm and 152/84 mm Hg in the left arm. The left radial pulse is diminished. ECG shows sinus tachycardia without ST-segment elevation. Initial troponin is normal. What is the most appropriate next step?
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Tearing pain to the back, a 32 mm Hg pressure difference between the arms, and a weak left radial pulse. That is aortic dissection until proven otherwise.
The first priority is protecting the aorta: lower shear stress with IV beta-blockade, then confirm with urgent CT angiography.
It looks like a heart attack, so A feels safe. But heparin and antiplatelets can be catastrophic in a dissection. No ST elevation and a normal troponin are your cue to stop.
C Thrombolysis is for unstable PE and would worsen dissection bleeding. D Pericarditis gives positional pain and diffuse ST elevation.
Tearing pain to the back plus unequal pulses or pressures: protect the aorta first. Beta-block, image urgently, call vascular or cardiothoracic surgery.
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TeachBack™ is Tutor Mode™, reimagined: a tutor layer built into every lesson and QBank question. After each answer it walks you through the stem, the key clue, the trap, why each wrong option is wrong, and what to review next, with audio you can replay anywhere.
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