Question

A 45 year old patient with hypertension presenting with acute severe chest pain & there is diaphoresis. Also there is h/o loss of consciousness, unequal pulses. In emergency condition which is the best one to make a diagnosis

• A. Cardiac enzymes
• B. MRI
• C. X-ray
• D. TEE

Hint:

Unequal pulses in a hypertensive patient with acute chest pain should point you away from ACS towards aortic pathology.

Answer 1

The Correct Option is D

Step 1: Identify the clinical scenario. A 45-year-old hypertensive male presents with acute severe chest pain, diaphoresis, loss of consciousness, and unequal pulses. The combination of hypertension, severe chest pain radiating with unequal pulses strongly suggests aortic dissection rather than a simple myocardial infarction.

Step 2: Rule out the other options.

• Cardiac enzymes (troponin, CK-MB) are elevated in myocardial infarction but take time and do not directly image the aorta.
• MRI is the gold standard for aortic dissection in stable patients but is not suitable in emergency/unstable settings due to prolonged scan time and limited monitoring.
• X-ray chest may show widened mediastinum but is neither sensitive nor specific enough to confirm aortic dissection.

Step 3: Identify the best emergency investigation. Transesophageal Echocardiography (TEE) is the best investigation in an emergency setting for aortic dissection. It can be performed at the bedside or in the operating room, provides real-time imaging of the aorta, detects the intimal flap, and assesses cardiac function simultaneously. It has sensitivity >95% and specificity >95% for Type A dissection. It does not require ionising radiation or contrast.