Dull Chest Pain in a 42-Year-Old Man

Ryland P. Byrd, Jr, MD; Thomas M. Roy, MD

Disclosures

June 12, 2017

Discussion

This case demonstrates the importance of the history and physical examination in a patient with chest pain. The ECG (Figure 2) demonstrated widespread diffuse ST-segment elevation, an absence of reciprocal ST-segment depression, and depressed PR segments in all leads except aVR and V1.

Figure 2.

This pattern is characteristic of pericarditis.[1] Although the ECG results are suggestive of pericarditis, other serious conditions can mimic or cause pericarditis and require urgent evaluation and treatment. The patient's history of a sudden tearing sensation at the onset of symptoms is a classic presentation for an acute aortic dissection; it would be atypical for a patient with an acute myocardial infarction. Patients with acute myocardial infarction may have a preceding history of exertional angina, or they may have substernal chest pressure and heaviness that is not positional (which are the classic findings).

In addition, this patient's physical examination gave important clues to the diagnosis. The patient was profoundly hypertensive, which in and of itself is a nonspecific finding. However, the finding of a blowing diastolic murmur in the aortic area (upper right sternal border) is always abnormal and requires urgent evaluation for proximal aortic pathology in patients with chest pain and hypertension.

Although the patient had equal blood pressures in both arms, this does not rule out an aortic dissection. Rather, equal blood pressures simply suggest that, if a dissection is present, the dissection flap does not impair circulation of either subclavian artery.

As part of his initial evaluation, this patient had chest radiography that showed mediastinal widening. Although this is also a nonspecific finding, it should prompt more in-depth cross-sectional imaging on the basis of the details described above.

In this case, the emergency department physician pursued further imaging by obtaining CT of the chest with the use of intravenous contrast, which disclosed a proximal dissection of the thoracic aorta.

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