Which features raise suspicion for acute aortic dissection in a chest pain patient?

• A. Pain relieved by antacids
• B. Sudden severe tearing chest or back pain; BP/pulse differential between arms; new murmur; mediastinal widening on chest radiograph; CT angiography to confirm
• C. Gradual chest pain with stable BP
• D. History of MI with ST elevations in leads II, III, aVF

Answer: (B)

Acute aortic dissection should be suspected when chest pain is abrupt and severe and raises concern for a vascular catastrophe. The hallmark is sudden tearing chest or back pain that patients often describe as sharp or ripping. When the dissection extends into the arteries that supply the arms, you can see a difference in blood pressure or pulse between the arms, reflecting unequal flow. A new murmur—often an early diastolic murmur from aortic regurgitation—can indicate valve involvement or root dilation caused by the dissection. Chest imaging may show mediastinal widening from an enlarged or dissecting aorta, another red flag guiding you toward this diagnosis. Definitive confirmation comes from CT angiography, which vividly shows the intimal tear, the true and false lumens, and how far the dissection has progressed. These features collectively distinguish acute dissection from other causes of chest pain. In contrast, pain relieved by antacids points to gastrointestinal etiologies, gradual chest pain with stable BP is less typical of an emergent dissection, and a history of MI with ST elevations suggests an acute coronary syndrome rather than a dissection.