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A 55-year-old man with a history of hypertension complains of substernal chest pain that started approximately 90 min ago during a bowel movement. The pain radiates to his back with diaphoresis and nausea. He does not have a history of ulcers, gastritis or previous coronary disease and does not take non-steroidal anti-inflammatory drugs. His vital signs are normal and his examination is notable only for diaphoresis. An ECG is done in triage showing 2 mm ST elevations in leads II, III and aVF.
What diagnoses other than acute ST-elevation myocardial infarction should be considered?
The other ‘can't miss’ chest pain diagnosis is aortic dissection, which can also cause an acute myocardial infarction (AMI) if the ascending aortic arch dissects proximally to the level of the origin of the coronary arteries. While it is standard to check a chest radiograph (CXR) in these patients, a normal-appearing mediastinum on CXR does NOT rule out an aortic dissection or aortic aneurysm, since the sensitivity of the CXR for aortic dissection is approximately 60–70%. However, since AMI is much more common than an aortic dissection, clinicians tend …
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