The most appropriate management for this patient is intravenous β-blockade followed by intravenous sodium nitroprusside. The CT scan (shown) reveals a focal penetrating atherosclerotic ulcer (PAU) in the proximal descending aorta (arrow), a type B acute aortic syndrome. PAU is a focal defect or lesion occurring at the site of an intimal atherosclerotic plaque. Patients tend to be older and with greater cardiovascular comorbidity. PAU occurs most commonly in the descending aorta, which may reflect a greater burden of atheromatous disease at this site. Elevation of the D-dimer level frequently accompanies acute aortic syndromes. Uncomplicated type B acute aortic injury is best treated medically, initially with β-blockade to decrease the heart rate to below 60/min followed by a parenteral arterial vasodilator as needed to control blood pressure.

Chest pain is a common presenting symptom in the emergency department, and three potentially lethal causes must be rapidly excluded: acute myocardial infarction, pulmonary embolism, and an acute aortic syndrome. Anticoagulation therapy would be considered standard of care if an acute coronary syndrome were suspected. In this patient, although a non–ST-elevation myocardial infarction cannot be excluded based on the electrocardiogram, it is less likely given his normal troponin I level; the troponin level would likely be elevated after 3 hours of ongoing cardiac ischemia. The patient also has a low pretest probability of pulmonary embolism by Wells scoring. Given his clinical and radiographic presentation, neither alternative diagnosis to an acute aortic syndrome is likely, and anticoagulation is not indicated in acute aortic syndrome.

Malperfusion syndromes are uncommon with an aortic penetrating atherosclerotic ulcer but could occur with transformation to classic dissection. In such cases, emergency endovascular stenting with or without fenestration may be necessary. This patient shows no evidence of lower limb or visceral malperfusion, and catheterization with endovascular repair is not indicated. Emergency open surgery is rarely indicated in this setting with the advent of endovascular therapies.