V6) Chest pain radiating to the back in a patient with uncontrolled hypertension

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with chest pain.
  2. Review the DDx considerations in a patient with chest pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with chest pain.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
This patient most likely is presenting acutely with an aortic dissection considering his risk factors (age and poorly controlled hypertension) and acute onset chest pain radiating to the back.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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Aortic dissection can be fatal if left untreated.

First Imaging Study

What is the first imaging study you will order?

CTA of the Chest, Abdomen, and Pelvis is a minimally invasive method to evaluate the aorta, its branches, and the organs it supplies.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

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View the full study if you'd like to take a look yourself.

Second Imaging Study

What is the next imaging study you will order?

No further imaging is needed as the diagnosis is confirmed with computed tomography.
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What is your Diagnosis now that you have seen the imaging results?

This patient has both a Stanford Type B Aortic Dissection and a thoracoabdominal aortic aneurysm.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient will require urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 65 y.o. male presenting with acute aortic dissection (Stanford Type B). The patient will require aggressive blood pressure control (target SBP <120mmHG) and heart rate control (HR<60). Vascular surgery should be urgently consulted for further management. Unless there are complications (end organ ischemia secondary to flow obstruction from a dissection flap), management for type B dissections is conservative. In this patient, the right kidney is at risk considering it is supplied by the false lumen and hypoenhances. Additionally, the patient will also need long-term follow-up (Serial CTAs or MRAs) and blood pressure control counseling.

Lessons Learned:
- Uncontrolled hypertension is a significant risk factor for aortic dissection. Other risk factors include hypertension, atherosclerosis, cardiac or aortic surgical history, aortic aneurysm, connective tissue disorders, and a bicuspid aortic valve.
- Presentation is typically characterized by sudden, severe, tearing chest pain that radiates to the back. 
- The first best diagnostic modality is a CTA of the chest, abdomen, and pelvis. Other first tests include transesophageal echocardiography and MRA chest with and without IV contrast.  

Socioeconomic Factors: Patients with lower socioeconomic status have been found to have reduced survival following an aortic dissection. Though formal studies do not investigate the matter, it is postulated that patients in lower socioeconomic classes have higher rates of aortic dissection considering the often inadequate blood pressure control in this population.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Jacob Surges, MS3 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh - Coordinator

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