Acute chest pain of cardiovascular aetiology: a diagnostic dilemma.
A 61-year-old gentleman was admitted to his local hospital with a 5-h history of central chest pain. He was an ex-smoker with no other cardiac risk factors or history of ischaemic heart disease. ECG on presentation demonstrated ST elevation in leads 1 and aVL consistent with acute myocardial infarction (MI) and he was therefore thrombolysed with tenecteplase. Following thrombolysis, his ST segment elevation resolved and his chest pain subsided completely. Peak CK was 1015 U/l (24–173 U/l) and troponin T 3.65 ug/l (0–0.10 ug/l). A routine PA chest radiograph revealed a widened superior mediastinum, raising the possibility of aortic dissection (Figure 1). An urgent contrast enhanced CT scan was therefore requested which demonstrated a type A aortic dissection with an aneurysmal ascending aorta (Figure 2). 



Figure 1. 
PA chest radiograph shows widening of the mediastinum and ectasia of the descending thoracic aorta. The lung fields are clear.





Figure 2. 
CT aorta demonstrates type A aortic dissection. In the dilated ascending aorta there is thrombus within the false lumen (asterisk). The dissection can be seen to extend into the descending thoracic aorta (arrow). T = true lumen.



Despite the CT findings, the patient remained well following thrombolysis with no subsequent clinical sequelae of acute aortic dissection. Further investigation with transthoracic echocardiography revealed good left ventricular function with no pericardial effusion. There was mild central aortic regurgitation but …