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Type A Dissection Clinical Triad — EECC MCQ

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EasyCoronary Artery DiseaseType A Dissection Clinical TriadEECC

A 45-year-old man with no prior cardiac history develops sudden-onset tearing chest pain radiating to the back. His BP is 190/110 in the right arm and 140/80 in the left arm. He has a new early diastolic murmur. What is the most likely diagnosis?

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Correct answer: E — Acute type A aortic dissection — the BP differential between arms (>20 mmHg) indicates involvement of a subclavian artery, and the early diastolic murmur indicates acute aortic regurgitation from disruption of the aortic root; this is a surgical emergency

The clinical triad of: (1) sudden severe tearing/ripping chest/back pain; (2) blood pressure differential between arms (>20 mmHg systolic — malperfusion of one subclavian artery by the dissection flap); (3) new aortic regurgitation murmur (dissection extending to the aortic root, disrupting the valve commissures) is highly suggestive of acute type A aortic dissection. Additional features: pulse deficit (any limb), neurological deficit (stroke from carotid malperfusion), abdominal pain (mesenteric ischaemia), limb ischaemia. The 2024 ESC Aortic Disease Guidelines: (1) CT aortography for diagnosis (sensitivity >95%); (2) type A = emergency surgical repair; (3) IV beta-blocker to HR <60 and SBP 100-120 while preparing for surgery. The ADD-RS (aortic dissection detection risk score) guides pre-test probability assessment and D-dimer testing (D-dimer <500 ng/mL with low ADD-RS effectively excludes dissection).

Reference: ESC (2024): Aortic Disease Guidelines