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Background
Aortic dissection (AD) and pulmonary embolism (PE) are both serious conditions that present to the emergency department. AD is one of the most common emergencies involving the aorta. The incidence of AD has been reported to be between 2000 and 3000 new cases per year and it has an estimated 1-2% per hour death rate in the first 24 h. 1 2 People with a type A AD, who manage to receive in-hospital treatment still have a high rate of mortality, despite surgical (27% mortality) and medical (56% mortality) management. 1
AD can be misdiagnosed at presentation in up to 38% of patients and can be painless in up to 15%. 3 As there are no validated clinical diagnostic tools to diagnose an AD, it is a matter of clinical judgment as well as clinician experience. The diagnosis is made further challenging given the myriad of clinical presentations. The classic 'interscapular tearing thoracic back pain' is present in only 51% of patients. 4
Similarly, acute PE may be present with or without the typical preceding signs of a deep venous thrombosis (DVT). 5 Therefore, overlapping presentations must be taken into account when considering these two differentials of chest pain. In accordance with the National Institute for Health and Clinical Excellence (NICE) guidelines, clinicians should offer low-molecular-weight-heparin (LMWH) to treat confirmed cases of PE taking into account any contraindications. 6
AD can be fatal if misdiagnosed as a PE. The two entities may present similarly, which makes it difficult to differentiate based on history and examination alone. Additionally, initial investigations may yield similar results such as an elevated D-dimer, which can be misleading. However, a CT scan is an effective tool in distinguishing between the two pathologies with a 98% sensitivity and 95% specificity at diagnosing an AD. 7
Case presentation
A 75-year-old Caucasian gentleman had a sudden onset of chest pain with associated dizziness and severe shortness of breath (SOB) that had lasted for 6 h. The incident occurred while gardening and there was no history of trauma. He described it as the worst pain he had felt with a severity of 10/10. The pain did not radiate. Nothing alleviated or worsened the pain. The patient noted a similar, but far milder, episode occurring...