A 66-year-old man with hypertension presents with sudden tearing chest and back pain, hypotension, and a diastolic murmur best heard at the base. What is the most likely diagnosis?

A 66-year-old man with hypertension presents with sudden tearing chest and back pain, hypotension, and a diastolic murmur best heard at the base. What is the most likely diagnosis?

• A. Pneumothorax
• B. Dissecting thoracic aneurysm
• C. Acute myocardial infarction
• D. Pulmonary embolus

Answer: (B)

Acute aortic dissection explains this picture. The sudden, tearing chest and back pain in a patient with hypertension is classic for dissection of the aorta. When the dissection involves the aortic root, it can disrupt the aortic valve and cause aortic regurgitation, which explains the diastolic murmur heard best at the base. Hypotension can occur if the dissection compromises blood flow to branches or leads to rupture into the pericardium with tamponade. Other conditions don’t fit as well: a pneumothorax usually has unilateral chest pain with abnormal breath sounds; an acute myocardial infarction presents with chest pressure and typically ST-se segment changes rather than a new diastolic murmur from valve involvement; a pulmonary embolus causes sudden dyspnea and pleuritic pain without a diastolic murmur from aortic insufficiency.

Acute aortic dissection explains this picture. The sudden, tearing chest and back pain in a patient with hypertension is classic for dissection of the aorta. When the dissection involves the aortic root, it can disrupt the aortic valve and cause aortic regurgitation, which explains the diastolic murmur heard best at the base. Hypotension can occur if the dissection compromises blood flow to branches or leads to rupture into the pericardium with tamponade.

Other conditions don’t fit as well: a pneumothorax usually has unilateral chest pain with abnormal breath sounds; an acute myocardial infarction presents with chest pressure and typically ST-se segment changes rather than a new diastolic murmur from valve involvement; a pulmonary embolus causes sudden dyspnea and pleuritic pain without a diastolic murmur from aortic insufficiency.