JUST ANOTHER CASE OF UNSTABLE ANGINA? G.J. Van Londen 1 , J. Hefner 1 ; 1 University of Pittsburgh, Pittsburgh, PA (Tracking ID #76750) LEARNING OBJECTIVES: 1.) Distinguish between Type A and B aortic dissections; 2.) Recognize an uncommon clinical presentation of an aortic dissection; 3.) Manage and treat a dissecting aorta. CASE INFORMATION: A 56-year-old male with a history of a 3-vessel coronary artery bypass graft in 1991, HTN and hyperlipidemia presented to the Emergency Room (ER) with bilateral jaw and retrosternal chest pain accompanied by an occipital headache and dyspnea on exertion. The chest pain was waxing and waning in intensity, non-radiating with a maximum pain score of 5/10. There was diaphoresis but no nausea or vomiting. The night prior, he noted some parathesias in his fingers and blurred vision that resolved within two hours. On exam, the patient's pulse was 110 with a BP of 130/80 on the left and 124/70 on the right. Room air pulse ox was 96%. No pulsus paradoxus, JVD or bruit was appreciated. Lung exam revealed decreased breath sounds in the left lower lobe. Cardiac exam was regular rhythm with a 2/6 diastolic murmur. Exam of the upper and lower extremities revealed equal and symmetric pulses. EKG showed sinus tachycardia with no ischemic changes. His first set of cardiac enzymes was negative. Portable chest x-ray revealed a left pleural effusion and a widening of the mediastinum with the patient rotated to the right. The patient was diagnosed in the ER with unstable angina and admitted. Based on the diastolic murmur and left pleural effusion on chest x-ray, an aortic dissection was suspected and a stat MRI was performed. This revealed a Type A dissection. Emergent surgery with replacement of the ascending aorta, valve and evacuation of a left hemothorax was performed. Cardiac arrests and a CVA complicated the perioperative course. The patient expired nine days after admission. IMPLICATIONS/DISCUSSION: A dissecting aorta must be recognized quickly as an acute Type A dissection (involves the ascending aorta) is a surgical emergency, whereas an uncomplicated Type B dissection (all others) can be treated with pharmacotherapy. Acute management consists of blood pressure control while confirming the diagnosis and type. Aortic dissection is relatively common with over 2000 cases reported each year. A recent study showed that 100% of dissections were diagnosed when all of the following clinical features were present: 1.) Acute onset of tearing or ripping-like chest or back pain; 2.) Mediastinal widening on chest x-ray and 3.) Variation in pulse and/or pressure in the upper extremities. A diastolic murmur, EKG without ischemic changes and a left-sided pleural effusion (hemothorax) are uncommon presentations of a dissection. Transesophageal echocardiogram (TEE) is recommended for unstable patients with acute chest pain. MRI is preferred in stable patients with chronic chest pain. CT scan or aortography should be reserved for situations in which both TEE and MRI are unavailable.