A 58-year-old man with longstanding hypertension presents with sudden-onset tearing chest pain radiating to the back. His blood pressure is 180/100 mmHg in the right arm and 150/90 mmHg in the left arm. Chest X-ray shows widening of the mediastinum. Which of the following is the MOST appropriate next investigation?
- A Transthoracic echocardiography
- B 12-lead ECG and serial troponins
- C Urgent coronary angiography
- D CT angiography of the chest with contrast ✓
Explanation
The clinical triad of tearing back pain, blood pressure differential between arms, and mediastinal widening is classic for aortic dissection. CT angiography is the investigation of choice as it rapidly identifies the intimal flap, extent of dissection, and involvement of branch vessels. Echocardiography can detect pericardial effusion and proximal aortic involvement but cannot reliably assess the descending aorta. Serial troponins address myocardial infarction, which is a far less likely diagnosis given the presentation. Coronary angiography is contraindicated as the first-line approach when dissection is suspected.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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