A 60-year-old hypertensive patient presents to the ED with chest pain. The pain came on very suddenly in the left chest whilst he was lifting a heavy plant pot. The pain is difficult to localize. The intensity has been constant and remains persistent. En route to hospital it has changed location to the left side of the lower thoracic back. He has recently had treatment for thoracic back pain from a chiropractor. He is sweating (looks unwell) and anxious but has no shortness of breath. Blood pressure is 160/90 mmHg, heart rate is 100 bpm and saturations are 99% on room air. The ECG does not show acute ST change. D-dimer is 1700 ng/mL (normal < 500 ng/mL), and troponin is awaited.
Based on the information available, what is the most likely diagnosis?
The question is designed to emphasize the importance of careful history to elicit the pre-test probability of a particular diagnosis. 75% of presentations to the ED with chest pain are of non-ischaemic aetiology. The history is highly suggestive of an aortic syndrome:
• sudden onset (no crescendo as in ACS);
• changing locations (reflecting propagation of dissection);
• strongly positive D-dimer (history does not suggest PE; negative D-dimer also has a high negative predictive value for aortic syndromes).