In a 79-year-old man presenting with shoulder and neck pain, sinus pressure above and below the eyes, left lower back pain worsened by deep inspiration, hypothermia, hypertension, and warm extremities, what emergent diagnosis should be considered and what immediate management is indicated?

Acute Aortic Dissection Must Be Ruled Out Emergently

This 79-year-old man requires immediate imaging (CT angiography) to exclude acute aortic dissection, followed by urgent hemodynamic stabilization with intravenous beta-blockers if dissection is confirmed. The constellation of shoulder/neck pain, sinus pressure, pleuritic left lower back pain, hypothermia (96.3°F), hypertension, and warm extremities raises critical concern for acute aortic syndrome with possible malperfusion 1.

Why Acute Aortic Dissection Is the Primary Concern

Clinical Presentation Matches Type A Dissection

• Sudden severe chest/back/shoulder pain is the hallmark of acute type A aortic dissection (acute TAAD), occurring in 93.6% of patients 1.
• Neck and shoulder pain specifically suggests proximal dissection involving the aortic arch and supra-aortic branches 1.
• Pleuritic left lower back pain worsened by deep breathing may indicate extension into the descending aorta or pleural involvement 1.
• Sinus pressure above and below the eyes could reflect referred pain from aortic arch involvement or cerebral malperfusion 1.

Atypical but Critical Features Present

• Hypothermia (96.3°F) with warm extremities and hypertension is paradoxical but can occur in dissection with autonomic dysregulation and peripheral malperfusion 1.
• Approximately 6.4% of acute TAAD patients present without typical pain, making atypical presentations diagnostically challenging 1.
• Hypertension is present in the majority of acute TAAD cases and reflects the underlying pathophysiology 1.

Mortality Risk Is Extreme Without Recognition

• 30-day mortality for acute aortic dissection ranges from 23% to 55.8% in Western Europe, including pre-hospital deaths 1.
• In-hospital mortality for medically treated acute TAAD is 58.6% in men, making surgical intervention time-critical 1.
• Early diagnosis remains a major pitfall in managing aortic dissection patients 1.

Immediate Diagnostic Algorithm

Step 1: Calculate ADD-RS Score and Obtain D-Dimer

• Use the Aortic Dissection Detection Risk Score (ADD-RS) combined with D-dimer to rule out acute aortic syndrome 1.
• D-dimer < 500 ng/mL makes acute aortic dissection unlikely, but levels are elevated in most cases 1.
• Do not delay imaging if clinical suspicion is high, even while awaiting laboratory results 1.

Step 2: Obtain Emergent CT Angiography

• CT angiography of the chest, abdomen, and pelvis is the definitive diagnostic test 1.
• Routine chest radiography and ECG should be obtained to exclude other etiologies, but their absence should not delay CT imaging 1.

Step 3: Assess for Malperfusion Syndromes

• Examine for unequal blood pressures between arms (≥20 mmHg difference suggests dissection) 2.
• Check for diminished or absent femoral pulses indicating iliac involvement 2.
• Evaluate for stroke, paraplegia, acute kidney injury, intestinal ischemia, or limb ischemia as complications of branch vessel involvement 1.

Immediate Management If Dissection Is Confirmed

Hemodynamic Stabilization: Beta-Blockers First-Line

Intravenous beta-blockade is the cornerstone of acute aortic dissection management and must be initiated immediately 1, 3, 2.

Target Hemodynamic Goals

• Heart rate ≤ 60 beats per minute 1, 3, 2.
• Systolic blood pressure < 120 mmHg (or lowest pressure maintaining end-organ perfusion) 1, 3, 2.
• These targets reduce aortic wall stress and prevent dissection propagation or rupture 1.

Preferred IV Beta-Blocker Agents

• Esmolol: 0.5–1 mg/kg IV bolus, then 50–300 µg/kg/min infusion (ultra-short acting, allows rapid titration) 2.
• Labetalol: 0.25–0.5 mg/kg IV bolus, then 2–4 mg/min infusion (combined α/β blockade provides additional afterload reduction) 1, 2.
• Metoprolol: 2.5–5 mg IV every 5 minutes, up to 15 mg total (β1-selective alternative) 2.

Add Vasodilators Only After Beta-Blockade

• Vasodilators must never be given before adequate heart rate control because they cause reflex tachycardia that increases aortic wall stress and may extend the dissection 1, 2.
• Once heart rate is controlled, add sodium nitroprusside (0.3–10 µg/kg/min IV) or nicardipine (5–15 mg/h IV) if systolic BP remains > 120 mmHg 2.

Critical Care Measures

• Place an arterial line immediately for continuous invasive blood pressure monitoring 1, 2.
• Admit to ICU for close hemodynamic monitoring and rapid drug titration 2.
• Administer IV morphine for pain control to attenuate sympathetic drive 2.
• Obtain urgent cardiothoracic surgical consultation regardless of dissection type 2.

Alternative Diagnoses to Consider (If Dissection Excluded)

Pulmonary Embolism

• Pleuritic chest pain and dyspnea are classic features 4.
• However, hypothermia and warm extremities are atypical for PE.
• CT pulmonary angiography would be diagnostic if aortic dissection is ruled out 4.

Acute Coronary Syndrome

• Shoulder and neck pain can represent ACS, but sinus pressure and pleuritic back pain are less typical.
• ECG and troponin should be obtained but should not delay aortic imaging 1.

Carotid Sinus Hypersensitivity

• Can cause syncope and hypotension in elderly patients 5, 6, 7.
• However, this does not explain the acute pain syndrome or hypertension in this case 6.

Common Pitfalls to Avoid

• Do not attribute symptoms to "sinus infection" or musculoskeletal pain without excluding life-threatening vascular pathology 1.
• Do not give vasodilators before beta-blockers in suspected dissection—this is a Class III contraindication (harm) 2.
• Do not delay imaging for laboratory results if clinical suspicion is moderate to high 1.
• Do not assume normal chest X-ray excludes dissection—mediastinal widening is present in only 60–70% of cases 1.