The most appropriate management for this patient with an acute type A aortic dissection is emergency surgical intervention. The abrupt onset of severe chest and back pain is typical of an acute aortic syndrome. A diastolic murmur consistent with aortic valvular insufficiency increases the clinical suspicion for a proximal (type A) aortic dissection that has disrupted normal valve leaflet coaptation. Acute aortic dissection is the most common life-threatening disorder affecting the aorta. In the Stanford classification, type A dissections involve the ascending aorta, and type B dissections are those that do not involve the ascending aorta. Type A dissections require emergency surgical repair, whereas medical therapy, consisting of a β-blocker to decrease the heart rate to below 60/min plus additional medications as needed to control hypertension, is usually the initial strategy for acute type B dissections. Therefore, pursuing medical management alone would not be appropriate in this patient. The immediate mortality rate in aortic dissection is as high as 1% per hour over the first several hours, making early diagnosis and treatment critical for survival.

Although most patients with dissection have underlying hypertension, only a tiny fraction of all persons with hypertension ever have a dissection. Syncope occurs in approximately 10% of patients with an acute aortic dissection and is more commonly associated with proximal dissection. Pulse deficits occur in less than 20% of type A dissections. Abnormal aortic contour or widening of the aortic silhouette may be an important clue to the diagnosis of aortic dissection. However, a normal chest radiograph is seen in nearly 15% of patients with acute aortic dissection. The 10-year survival rate of patients with acute dissection who survive initial hospitalization is reported to be 30% to 60%.

Endovascular treatment of dissection is used as an alternative to open surgery primarily in complicated type B dissections. Although endovascular procedures for type A dissections have shown some promise, they are not routinely used, particularly in patients with valve dysfunction requiring surgical repair.

Although heparin is commonly used in the initial treatment of acute coronary syndromes and pulmonary embolism, heparin is not indicated in the setting of an acute type A aortic dissection. The use of heparin in this setting can be complicated by major bleeding and cardiac tamponade. Moreover, heparin can increase the risk of life-threatening major bleeding when used in patients with very elevated blood pressures (commonly seen during a dissection).