62-Year-Old Female with Acute Substernal and Epigastric Pain

A 62-year-old female with a medical history of asthma who presents to the emergency department (ED) with acute substernal/epigastric pain that radiates to her mid-back. The pain started abruptly while at rest and has gotten progressively worse on transport to the ED. Pain is associated with nausea, sweating and dyspnea. Patient reports that she has never experienced pain like this before.

On physical exam blood pressure is 169/91 mmHg in the right arm and 165/89 mmHg, pulse is 70 bpm, temperature is 97.7°F and SpO2 is 100% on room air. The patient is in no acute distress, heart rate and rhythm are regular, no murmurs appreciated. Pulses are 2+ throughout with trace bilateral pedal edema. Lungs are clear to auscultation with normal pulmonary effort. Patient endorses tenderness to palpation over lower sternum.

Laboratory work including troponin, basic chemistry and complete blood count are within normal limits. Electrocardiogram (ECG) demonstrates lateral T wave inversions. Chest x-ray shows no acute cardiopulmonary disease.

Computed tomography angiography (CTA) demonstrates a crescentic, high density thickening of the wall of the thoracic aorta beginning in the proximal descending thoracic aorta at the aortic isthmus and extending roughly to the diaphragmatic hiatus (Figure 1). The ascending aorta and aortic arch do not appear to be involved. The proximal great vessels appear to be unremarkable, and the thoracic aorta is normal in caliber.

Figure 1

Figure 1
Figure 1: CTA chest demonstrating a crescentic high density thickening of the wall of the descending thoracic aorta.

What is the next appropriate step in management of this patient?

Show Answer