Radiating chest pain to the back.

A 69-year-old woman presented to an outside hospital with chest pressure radiating to the back and dyspnea. Computed tomography (CT) of the chest with pulmonary embolism protocol for elevated D-dimer was negative (Figure 1). She had mild Troponin elevation that resolved along with the symptoms, and the patient underwent a stress test to rule out acute coronary syndrome. She developed dys-pnea during the test, prompting a chest x-ray, which showed left-sided pleural effusion and mediastinal shift to the right that was not seen on the admission chest x-ray (Figure 2). A tho-racentesis demonstrated hemorrhagic fluid. A CT of the chest without contrast showed an intimal flap in the aorta with a centrally displaced calcified atherosclerotic plaque characteristic of aortic dissection that could not be seen in the previous CT with pulmonary embolism protocol (Figure 3). After this, she was transferred to our hospital, where a transthoracic echocar-diogram almost 6 hours later showed a type I aortic dissection with the intimal flap originating 1.5 cm proximal to the aortic valve and extending into left subclavian artery and descending aorta (Figures 4 and 5 and Movies I and II in the online-only Data Supplement). There was no involvement of the coronary cusps, and no regional wall motion abnormalities of the myocardium. A transesophageal echocardiogram showed the dissection in addition to mediastinal fluid surrounding the aor-tic arch, suggestive of rupture (Movie IIII in the online-only Data Supplement). CT angiography performed to evaluate the Figure 1. Computed tomography of the chest with pulmonary embolism protocol. No luminal filling defects can be visualized in the pulmonary arteries, and no intimal flap can be seen in the ascending and descending aorta. Figure 2. Chest x-ray. Initial chest x-ray (left) compared with the chest x-ray after the stress test (right) with what was eventually found to be a hemorrhagic effusion.