Q. A 66-year-old man presents with central chest pain radiating to the arm and the scapula. He has a history of hypertension and diabetes. He takes aspirin, gliclazide and metformin. On examination, he has absent pulses in the right arm and an irregularly irregular heartbeat. The blood pressure is 160/100 mmHg. He also complains of some left sided arm and leg weakness compared to the right. ECG showed significant ST elevation in leads II, III, aVf. His troponin I was 10 (normal less than 0.02).
What should be next line of management?
What should be next line of management?
A. I/V thrombolysis
B. Primary PCI for myocardial infarction
C. CT aortography
D. NCCT head
Answer: C. CT aortography
Explanation:
The patient has chest pain mimicking the clinical history of myocardial infarction but has two other features (absent pulses unilaterally and hemiparesis) which could be manifestations of occlusion of vascular supply from the aorta. In aortic dissection, if the dissection flap occludes the blood supply to the right arm (subclavian artery) then an absent pulse may occur and if the flap occludes the blood supply to the brain (carotid arteries) a hemiparesis can occur. CT aortography is indicated to diagnose acute aortic dissections.
With acute ascending aortic dissection, RCA occlusion is most common hence may have inferior wall MI. Patient will require urgent cardiovascular surgery for definitive management as mortality is this setting is very high without surgery.
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