03-07-2010, 07:03 AM
A 44-year-old man with a history of hypertension
that is poorly controlled presents to the emergency room
complaining of severe chest pain. The pain began
abruptly this afternoon while at rest. He describes the
pain as tearing and radiates to the back. He also is complaining
of feeling lightheaded but does not have nausea
or vomiting. He has never had a similar episode of pain
and is usually able to exercise at the gym without chest
pain. In addition to hypertension, he also has a history of
hypercholesterolemia. He has been prescribed felodipine,
10 mg once daily, and rosuvastatin, 10 mg once
daily, but says that he only takes them intermittently. He
smokes 1 pack of cigarettes daily and has done so since
the age of 20. His family history is significant for coronary
artery disease in his father, who had a heart attack
at the age of 60. On physical examination, the patient appears
uncomfortable and diaphoretic. Vital signs: blood
pressure is 190/110 mmHg, heart rate is 112 beats/min,
respiratory rate is 26 breaths/min, temperature is 36.3°C,
and SaO2 is 98% on room air. His carotid pulses are full
and bounding. His cardiac examination reveals a hyperdynamic
precordium. The rhythm is tachycardic but regular.
An S4 is present. There is a II/VI diastolic murmur
heard at the lower left sternal border. An electrocardiogram
(ECG) shows 1 mm of ST elevation in leads II, III,
and aVF. A contrast-enhanced chest CT shows a dissection
of the ascending aorta with a small amount of pericardial
fluid. What is the most appropriate management
of the patient?
A. Emergent cardiac catheterization
B. Emergent cardiac surgery
C. Intravenous nitroprusside and esmolol alone
D. Intravenous nitroprusside and esmolol and cardiac
surgery emergently
E. Thrombolysis with tenecteplase
that is poorly controlled presents to the emergency room
complaining of severe chest pain. The pain began
abruptly this afternoon while at rest. He describes the
pain as tearing and radiates to the back. He also is complaining
of feeling lightheaded but does not have nausea
or vomiting. He has never had a similar episode of pain
and is usually able to exercise at the gym without chest
pain. In addition to hypertension, he also has a history of
hypercholesterolemia. He has been prescribed felodipine,
10 mg once daily, and rosuvastatin, 10 mg once
daily, but says that he only takes them intermittently. He
smokes 1 pack of cigarettes daily and has done so since
the age of 20. His family history is significant for coronary
artery disease in his father, who had a heart attack
at the age of 60. On physical examination, the patient appears
uncomfortable and diaphoretic. Vital signs: blood
pressure is 190/110 mmHg, heart rate is 112 beats/min,
respiratory rate is 26 breaths/min, temperature is 36.3°C,
and SaO2 is 98% on room air. His carotid pulses are full
and bounding. His cardiac examination reveals a hyperdynamic
precordium. The rhythm is tachycardic but regular.
An S4 is present. There is a II/VI diastolic murmur
heard at the lower left sternal border. An electrocardiogram
(ECG) shows 1 mm of ST elevation in leads II, III,
and aVF. A contrast-enhanced chest CT shows a dissection
of the ascending aorta with a small amount of pericardial
fluid. What is the most appropriate management
of the patient?
A. Emergent cardiac catheterization
B. Emergent cardiac surgery
C. Intravenous nitroprusside and esmolol alone
D. Intravenous nitroprusside and esmolol and cardiac
surgery emergently
E. Thrombolysis with tenecteplase