17 Sept 2026
Patient history
A 58-year-old man develops sudden, severe chest pain while gardening: a tearing sensation between the shoulder blades, at maximum intensity the instant it began. He has hypertension but stopped his medication a year ago.
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Aortic dissection (Stanford type A)
Emergency surgical repair, with IV beta blockade while awaiting theatre
Pain that is maximal at the very first instant is the discriminator. Myocardial ischaemia builds over minutes as the muscle starves, whereas a tear happens all at once, and a tearing quality radiating to the back fits that mechanism. Everything else on examination follows from a flap propagating along the aorta. The inter-arm pressure difference and asymmetric pulses mean the flap has reached the brachiocephalic vessels and is intermittently obstructing them, and the early diastolic murmur is aortic regurgitation from a disrupted valve annulus, which puts the dissection in the ascending aorta. The mildly raised troponin is the trap this case is built around: a flap can shear a coronary ostium and produce genuine ischaemia, and anchoring on that number sends the patient to the catheter lab or, far worse, to thrombolysis, which is close to lethal here. The ECG is the counterweight, and it earns its place by what it lacks: sinus tachycardia with the tall voltages of left ventricular hypertrophy from years of untreated pressure, non-specific T-wave flattening in the lateral leads, and no ST elevation, no reciprocal depression and no territory that evolves across serial tracings. A troponin rise without any of that is not an occluded coronary artery. Long-standing untreated hypertension is the risk factor that made the wall vulnerable in the first place. A Stanford type A dissection involves the ascending aorta and is an operative emergency, with mortality climbing roughly 1 to 2 per cent per hour, so definitive treatment is emergency open repair. While theatre is readied, intravenous beta blockade with esmolol or labetalol brings heart rate under 60 and systolic pressure to 100 to 120, which lowers the shear force driving the tear onward. The order is not negotiable: beta blockade precedes any vasodilator, because a vasodilator given first provokes reflex tachycardia and extends the dissection. Uncomplicated type B dissections are managed medically.