Radiating Chest Pain to the Back

Abstract

A 69-year-old woman presented to an outside hospital with chest pressure radiating to the back and dyspnea. Computed tomography (CT) of the chest with pulmonary embolism protocol for elevated D-dimer was negative ( Figure 1). She had mild Troponin elevation that resolved along with the symptoms, and the patient underwent a stress test to rule out acute coronary syndrome. She developed dyspnea during the test, prompting a chest x-ray, which showed left-sided pleural effusion and mediastinal shift to the right that was not seen on the admission chest x-ray ( Figure 2). A thoracentesis demonstrated hemorrhagic fluid. A CT of the chest without contrast showed an intimal flap in the aorta with a centrally displaced calcified atherosclerotic plaque characteristic of aortic dissection that could not be seen in the previous CT with pulmonary embolism protocol (Figure 3). After this, she was transferred to our hospital, where a transthoracic echocardiogram almost 6 hours later showed a type I aortic dissection with the intimal flap originating 1.5 cm proximal to the aortic valve and extending into left subclavian artery and descending aorta (