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Cardiology

An Uncommon Cause of Acute Chest Pain

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JAMA Internal Medicine

Published Online: February 20, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Yanmei Song, BS¹;

Xiaowei Zhang, MD, PhD¹;

Tong Liu, MD, PhD¹

Author Affiliations

¹Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People’s Republic of China

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A patient in their 50s presented to the emergency department with 20 minutes of substernal chest pain radiating to the left shoulder and back, which was accompanied by shortness of breath and sweating. The patient’s medical history was notable for poorly controlled hypertension and heavy smoking. On admission, the patient’s blood pressure was 185/104 mm Hg in the right upper limb and 113/98 mm Hg in the left upper limb, their heart rate was 58 beats per minute, and their oxygen saturation level was 98% on room air. A faint early diastolic murmur was found in the aortic area, and the lungs were clear. Subsequent investigation revealed a D-dimer level of 3.914 μgm/L (normal value,0-0.3 μg/mL; to convert to nmol/L, multiply by 5.476), and a troponin I level within normal range. An electrocardiogram (ECG) obtained on admission is shown in the Figure.

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Differential diagnoses for acute chest pain mainly include pulmonary embolism (PE), acute coronary syndrome, and acute aortic syndrome (AAS). Acute aortic syndrome consists of acute aortic dissection (AAD), intramural hematoma, and penetrating atherosclerotic ulcer. Aortic dissection is defined as the disruption of the medial layer provoked by intramural bleeding, in which is followed by separation of the aortic wall layers and subsequent formation of a true lumen and false lumen. A case of AAD or intramural hematoma involving the ascending aorta and aortic arch is defined as type A aortic syndrome; if only the descending aorta is involved, it is type B aortic syndrome.¹ Typical chest pain of AAD usually presents with tearing chest pain that radiates to the back, and physicians should be aware of possibility of AAD in such cases.

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Article Information

Corresponding Authors: Xiaowei Zhang, MD, PhD (doczxw@126.com) and Tong Liu, MD, PhD (liutong@tmu.edu.cn), Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Department of Cardiology, Second Hospital of Tianjin Medical University, No. 23 Pingjiang Rd, Hexi District, Tianjin 300211, People’s Republic of China.

Published Online: February 20, 2023. doi:10.1001/jamainternmed.2022.6451

Conflict of Interest Disclosures: None reported.

Funding/Support: The work was funded by Tianjin Key Medical Discipline (specialty) construction project TJYXZDXK-029A.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Nan Zhang, BS, Second Hospital of Tianjin Medical University, for her helpful comments. She was not compensated.

References

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

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