A 55-year-old man with sudden ripping chest pain and diminished pulses; what is the most likely diagnosis?

• A. Acute myocardial infarction
• B. Pulmonary embolism
• C. Acute pericarditis
• D. Aortic dissection

Answer: (D)

The main concept is that sudden, severe tearing chest pain with diminished pulses points to aortic dissection. The tearing quality comes from a tear in the inner lining of the aorta that allows blood to split the vessel wall, creating a false lumen. When this process involves branches of the aorta, it can cause unequal or diminished pulses in one or more limbs and signs of end-organ malperfusion, which fits the scenario of a 55-year-old with chest pain and pulse deficits. Hypertension and age are common risk factors that raise suspicion for this condition.

This presentation is distinct from a heart attack, where the pain is typically pressure-like or squeezing and not described as tearing, and pulse deficits are not a defining feature. Pulmonary embolism usually causes sudden pleuritic chest pain with shortness of breath and hypoxia rather than a tearing pain with pulse discrepancies. Acute pericarditis features sharp chest pain that can improve when leaning forward and may have a pericardial friction rub rather than pulse differences.

If suspected, prioritize rapid imaging to confirm/disconfirm dissection (CT angiography if stable, or transesophageal echo if unstable). Begin beta-blockade promptly to lower shear stress on the aorta (target heart rate around 60, with blood pressure controlled), and involve vascular or cardiothoracic surgery emergently for type A dissections. Avoid anticoagulation or thrombolysis in dissection, as these worsen bleeding within the vessel wall.