A 34-year-old man, tall and thin, presents with sudden interscapular pain, BP differential 30 mmHg between arms, and a new diastolic murmur. How would you proceed?

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Accepted Answer

This is an **acute aortic syndrome until proven otherwise**. Pre-test probability is very high — Marfanoid habitus, classic interscapular tearing pain, inter-arm BP differential, new diastolic murmur of aortic regurgitation. **Aortic Dissection Detection (ADD) risk score** is ≥2; do not delay imaging for D-dimer.

**ABCDE.** Two large-bore IV access, arterial line, **cross-match 6 units**, bloods including troponin, U&E, lactate, coagulation. 12-lead ECG to exclude inferior STEMI (RCA occlusion from dissection flap). Avoid thrombolysis, antiplatelets and anticoagulation.

**Impulse control — the critical first intervention.** Target **SBP 100–120 mmHg and HR <60** to reduce aortic wall stress. Start IV **labetalol** (or **esmolol**) **before** any vasodilator — adding GTN without beta-blockade triggers reflex tachycardia and propagates dissection. Generous analgesia (morphine) reduces sympathetic drive.

**Imaging.** **Gated CT aorta from arch to femorals** is the investigation of choice (sensitivity and specificity >95%). If too unstable to move, **TOE in resus**. Bedside TTE to look for pericardial effusion (tamponade), AR severity, and proximal flap.

**Classify and escalate.**
- **Type A** (involving ascending aorta) — **emergency cardiothoracic surgery**, call the tertiary aortic centre *now*; transfer in parallel with imaging.
- **Type B uncomplicated** — medical management, BP control, HDU/ITU.
- **Type B complicated** (malperfusion, rupture, refractory pain, progression) — **TEVAR**.

**Multidisciplinary.** Cardiothoracic surgery, vascular surgery, ITU, anaesthetics, transfusion lab, family.

**Underlying cause.** In a 34-year-old, screen for **connective tissue disease** — Marfan (FBN1), Loeys-Dietz, vascular Ehlers-Danlos; family screening, genetics referral.

**Communication.** Frank conversation with the patient and family about a high-mortality emergency, the urgency of surgery, and family screening implications. Document and Datix any delay in diagnosis.

Atypical acute aortic dissection in a young patient

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