A patient with sudden tearing chest pain radiating to the back and unequal arm blood pressures is most concerning for which condition?

• A. Aortic dissection
• B. Myocardial infarction
• C. Pulmonary embolism
• D. Pneumothorax

Answer: (A)

The key idea here is recognizing acute aortic dissection. When the aorta tears, blood splits the wall and creates a false channel. This causes sudden, severe chest pain described as tearing or ripping, often radiating to the back. The dissection can involve arteries branch vessels, leading to unequal blood pressures in the arms as one limb may receive less blood flow than the other. That combination of abrupt, tearing pain with back radiation and a noticeable BP discrepancy is classic for dissection and signals a medical emergency requiring rapid imaging and coordinated management.

This presentation is not typical of a heart attack, which usually presents as pressure-like chest pain and is evaluated with ECG and cardiac enzymes rather than a focus on back radiation or limb BP differences. It’s not the usual picture for a pulmonary embolism, which tends to be chest pain with shortness of breath and hypoxemia, not tearing pain with unequal arm pressures. And it’s not a pneumothorax, which would more commonly show unilateral chest findings and breath sounds changes rather than a tearing pain pattern with BP asymmetry.

Timely diagnosis is typically made with CT angiography to define the dissection; management focuses first on controlling heart rate and blood pressure to reduce shear forces (beta-blockade to lower heart rate and systolic pressure), followed by surgical evaluation if the ascending aorta is involved, as these cases carry high risk of life-threatening complications.