A 54-year-old man presents with sudden tearing chest pain radiating to the back. The left brachial pulse is absent while the right radial pulse is normal. A new soft early diastolic murmur is heard and the chest radiograph shows a widened mediastinum. What is the definitive next step?
- A Intravenous labetalol and transthoracic echocardiographic surveillance every 6 hours
- B Thrombolysis with tenecteplase followed by anticoagulation
- C Urgent contrast CT aortography followed by emergency surgical repair ✓
- D Percutaneous aortic valve replacement for the new aortic regurgitation
Correct answer: C. Urgent contrast CT aortography followed by emergency surgical repair
Explanation
Acute aortic regurgitation with pulse deficit in a patient with tearing chest pain indicates proximal (Stanford type A) aortic dissection involving the root. Type A dissection is a surgical emergency because of risk of tamponade, rupture and stroke; imaging with CT aortography confirms anatomy and branch involvement, then open repair is performed. Medical therapy alone is reserved for uncomplicated distal dissections, and thrombolysis would be catastrophic.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.