A fictional 66-year-old with hypertension develops abrupt severe chest pain radiating to the back, a new pulse asymmetry and a 28 mmHg systolic blood-pressure difference between arms.
Frame the danger first.
- Abrupt severe chest, back or abdominal pain with pulse, blood-pressure, neurological or aortic-regurgitation findings should raise concern for acute aortic syndrome.
- No single symptom or examination sign safely confirms or excludes dissection; combine history, examination and structured risk assessment.
- A normal ECG or an elevated troponin does not resolve the differential between acute coronary syndrome and aortic disease.
Act, escalate, reassess.
- Begin ABCDE assessment, monitoring, analgesia and immediate senior escalation while activating the local acute-aortic-syndrome pathway.
- Discuss definitive aortic imaging urgently with radiology and the accepting aortic team; use the locally agreed CT aortogram protocol when appropriate.
- Seek senior critical-care and cardiovascular guidance for controlled reduction of aortic wall stress, accounting for perfusion, aortic regurgitation and contraindications.
- Avoid reflex antiplatelet, anticoagulant or thrombolytic treatment until the competing diagnoses and bleeding risk have been assessed.
Red flags that change pace.
- Shock, syncope, tamponade physiology or rapidly changing haemodynamics
- New focal neurology, limb ischaemia, mesenteric or renal malperfusion
- New aortic-regurgitation features, heart failure or persistent severe pain
What makes care less safe.
- Calling the pain ACS before considering lethal alternatives
- Waiting for troponin before arranging definitive imaging
- Transfer without agreed blood-pressure, heart-rate, analgesia and deterioration instructions
Say the concern plainly.
Suspected acute aortic syndrome with pain onset [time/pattern], haemodynamics [trend], pulse/BP/neurological findings [summary] and complications [present/absent]. Imaging and images are [status]; stabilisation is [status]. I need immediate aortic-centre advice and a safe transfer plan.