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A 62-year-old hypertensive man presented with central chest pain of sudden onset associated with shortness of breath. He denied back pain, but complained of bilateral hip pain.
An ECG showed inferior ST elevation with lateral ST depression (panel A); thrombolysis was not administered by the ambulance crew owing to hypotension of 79/43 mm Hg, he was given fluid resuscitation.
Upon arrival at the emergency department he was still complaining of hip pain, and was found to have a flaccid paraparesis and a sensory level at L1. Computed tomography of the thoracic and abdominal aorta with contrast showed a large aortic dissection, affecting the right coronary sinus and extending distally to involve the anterior spinal arteries and renal arteries (panel B).
This case demonstrates the importance of considering aortic dissection as a differential diagnosis for central chest pain, even in the absence of back pain or significant blood pressure differences in both arms, and in the presence of classic ECG changes for ST elevation myocardial infarction.
In this case the extent of the dissection provided a clue to the diagnosis, but had this been a smaller dissection with a more robust blood pressure, thrombolysis might well have been given.
This article has been adapted from Tarver K, Kindler H, Lythall D. Extensive aortic dissection presenting as acute inferior myocardial infarction Heart 2007;93:1225
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