Dull Chest Pain in a 42-Year-Old Man

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


June 12, 2017

Acute medical therapy is directed at stabilizing the patient, preventing further propagation of the dissection, and enabling the patient to survive until definitive operative therapy can be performed. The acute medical therapy is termed "anti-impulse" therapy and commonly uses intravenous vasodilators (nitroprusside) and beta-blockers (intravenous esmolol, labetalol, metoprolol) to decrease the force of cardiac contractions.[2] The goal of acute medical therapy is to obtain a blood pressure that is as low as possible while still maintaining mentation and end-organ perfusion.

Surgical correction is mandated for any symptomatic aortic dissection. The surgical procedure commonly involves various forms of resection and reapproximation of the dissection flap. The degree of surgical complexity is based on other vascular or valvular structures involved in the dissection. For example, in the case of severe aortic valvular regurgitation complicating a dissection, replacement of the aortic valve may be required. Another nonsurgical approach for the treatment of aortic dissection involves percutaneous placement of an endovascular stent graft to cover the dissection flap and restore the true aortic lumen.

The appropriate patient selection and outcomes of patients who receive stent grafts are areas of current investigation. The experience of the surgeon and surgical center is critical in assessing the appropriate type of surgical repair and ensuring a good outcome. In high-volume centers, the survival rate in acute aortic dissection is over 85%.[2]

The patient in this case was treated with propranolol and nitroprusside in preparation for surgery. He subsequently underwent surgical repair of a proximal aortic dissection with extension into the pericardium and did well postoperatively.

Acknowledgment: Special thanks are extended to John Vozenilek, MD, for his contributions to the publication of this case.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.