In a 75‑year‑old woman with hypertension who presents with back pain and cough and imaging shows a tortuous thoracic aorta, what is the appropriate diagnostic work‑up and management?

Diagnostic Work-Up and Management of Tortuous Thoracic Aorta with Back Pain and Cough

This 75-year-old woman with hypertension presenting with back pain requires urgent CT angiography of the chest to exclude acute aortic dissection, penetrating atherosclerotic ulcer, or impending rupture—all life-threatening complications that can present with back pain in patients with tortuous thoracic aortas. 1

Immediate Risk Assessment

This patient's presentation is high-risk based on multiple factors:

• Age >65 years with hypertension and back pain represents the classic triad for penetrating atherosclerotic ulcer (PAU), which occurs in the descending thoracic aorta in >90% of cases 2
• Back pain in the setting of known aortic pathology cannot be safely ruled out by clinical assessment alone and mandates definitive imaging 1
• The cough may represent mass effect from aortic enlargement or associated pathology 3

Urgent Diagnostic Workup

First-Line Imaging

Obtain CT angiography of the chest with ECG-gating immediately as the diagnostic modality of choice, with 100% sensitivity and 98-99% specificity for acute aortic syndrome 1. The scan must:

• Extend from above the aortic arch through the abdomen and pelvis to assess branch vessel involvement and potential malperfusion 2
• Use ECG-gating for motion-free images of the aortic root and ascending aorta 1
• Include standardized perpendicular measurements at multiple locations to assess for interval growth or aneurysm formation 2
• Use contrast delivery at 3-5 mL/s with total volume ≤150 mL 2

Adjunctive Testing

• Obtain ECG immediately to exclude ST-elevation myocardial infarction, though do not delay aortic imaging even if ST-elevations are present 1
• Chest X-ray findings such as widened mediastinum or abnormal aortic contour support the diagnosis, but a normal chest X-ray should NOT delay definitive imaging in this high-risk patient 1, 4
• D-dimer levels <500 ng/mL make acute aortic dissection unlikely, but cannot be used to rule out dissection in high-risk patients with known aortic pathology 1

Physical Examination Priorities

Assess for findings associated with acute aortic syndromes:

• Blood pressure in both arms—differential >20 mmHg suggests dissection 4
• Peripheral pulse examination for deficits indicating malperfusion 4
• Cardiac auscultation for new diastolic murmur of aortic regurgitation 4
• Neurologic examination for focal deficits 4

Immediate Medical Management

Initiate anti-impulse therapy immediately while awaiting imaging, with target systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute to reduce aortic wall stress 1:

• First-line: Intravenous beta-blockers, with labetalol preferred due to combined alpha- and beta-blocking properties 1
• Critical pitfall: Never administer vasodilators before achieving rate control, as this can increase aortic wall stress 1

Management Based on Imaging Results

If Acute Dissection Confirmed

• Type A dissection (ascending aorta): Immediate cardiothoracic surgery consultation for emergency open surgical repair 1
• Type B dissection (descending aorta): Initial medical management unless complicated by malperfusion, uncontrolled pain/hypertension, or progression 1

If Penetrating Atherosclerotic Ulcer Identified

PAU presents as a mushroom-like outpouching with overhanging edges on imaging 2. These lesions can progress to intramural hematoma, dissection, or frank rupture 2. Management depends on size and symptoms, but symptomatic PAU typically requires intervention.

If Tortuous Aorta Without Acute Pathology

The tortuosity itself may cause:

• Dysphagia from esophageal compression at multiple levels, managed with dietary adjustment and optimal blood pressure control 3
• Increased risk of future aneurysm formation, particularly with uncontrolled hypertension 5, 6

Long-Term Management

For patients with tortuous thoracic aorta without acute pathology:

• Beta-blocker therapy to reduce aortic wall stress and slow progression 1
• Blood pressure control to target <130/80 mmHg—central hypertension (central systolic BP ≥130 mmHg) is independently associated with larger aneurysm size and faster growth even when brachial BP is normal 6
• Statin therapy for atherosclerotic plaque reduction 1
• Smoking cessation and diabetes control 1
• Serial imaging surveillance if aortic diameter approaches aneurysmal thresholds (≥50% enlargement over normal or >2 standard deviations above mean for age/sex) 2

Critical Pitfalls to Avoid

• Never delay definitive imaging based on normal chest X-ray in high-risk patients 1
• Never use D-dimer alone to exclude dissection in patients with known aortic pathology and back pain 1
• Never assume tortuosity is benign in elderly hypertensive patients presenting with new back pain—this represents the classic presentation for PAU 2
• Do not overlook occult central hypertension—15% of TAA patients without diagnosed hypertension have elevated central BP despite normal brachial readings 6