A 62-year-old man is brought to the emergency department with a sudden onset of severe chest pain, that he describes as tearing. The pain started 90 minutes back and is now referring to the upper back. There is a history of essential hypertension for the past 17 years. The patient has smoked 20–30 cigarettes daily for the past 27 years. Vital signs reveal: temperature 36.8°C (98.2°F), heart rate 105/min, and blood pressure 192/91 mm Hg in the right arm and 159/81 mm Hg in the left arm. Pulses are absent in the right leg and diminished in the left. ECG shows sinus tachycardia, and chest X-ray shows a widened mediastinum. Transthoracic echocardiography shows an intimal flap arising from the ascending aorta and extended to the left subclavian artery. Intravenous morphine sulfate is started. Which of the following is the best next step in the management of this patient condition?

Chest magnetic resonance imaging

A 32-year-old woman who recently emigrated to the USA from Japan comes to the physician because of a 3-month history of night sweats, malaise, and joint pain. During this time, she has also had a 6-kg (13-lb) weight loss. Physical examination shows weak brachial and radial pulses. There are tender subcutaneous nodules on both legs. Carotid bruits are heard on auscultation bilaterally. Laboratory studies show an erythrocyte sedimentation rate of 96 mm/h. A CT scan of the chest shows thickening and narrowing of the aortic arch. Microscopic examination of the aortic arch is most likely to show which of the following findings?

Granulomatous inflammation of the media

Fibrinoid necrosis of the intima and media

Subendothelial hyaline deposition

Subendothelial immune complex deposition

A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

Perforation of the esophageal wall

Obstruction of the pulmonary arteries

Fibrofatty plaque in the aortic wall

A previously healthy 32-year-old man comes to the physician because of a 1-week history of upper back pain, dyspnea, and a sensation of pressure in his chest. He has had no shortness of breath, palpitations, fevers, or chills. He emigrated from Ecuador when he was 5 years old. He does not smoke or drink alcohol. He takes no medications. He is 194 cm (6 ft 4 in) tall and weighs 70.3 kg (155 lb); BMI is 19 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 73/min, respirations are 15/min, and blood pressure is 152/86 mm Hg in the right arm and 130/72 mm Hg in the left arm. Pulmonary examination shows faint inspiratory wheezing bilaterally. A CT scan of the chest with contrast is shown. Which of the following is the most likely underlying cause of this patient's condition?

Atherosclerotic plaque formation

Congenital narrowing of the aortic arch

Infection with Trypanosoma cruzi

A 55-year-old man presents to the emergency department for chest pain. He states that the pain started last night and has persisted until this morning. He describes the pain as in his chest and radiating into his back between his scapulae. The patient has a past medical history of alcohol abuse and cocaine abuse. He recently returned from vacation on a transatlantic flight. The patient has smoked 1 pack of cigarettes per day for the past 20 years. His temperature is 99.5°F (37.5°C), blood pressure is 167/118 mmHg, pulse is 120/min, and respirations are 22/min. Physical exam reveals tachycardia and clear air movement bilaterally on cardiopulmonary exam. Which of the following is also likely to be found in this patient?

Asymmetric blood pressures in the upper extremities

A 71-year old man is brought to the emergency department because of progressively worsening shortness of breath and fatigue for 3 days. During the last month, he has also noticed dark colored urine. He had an upper respiratory infection 6 weeks ago. He underwent a cholecystectomy at the age of 30 years. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He immigrated to the US from Italy 50 years ago. Current medications include simvastatin, lisinopril, and metformin. He appears pale. His temperature is 37.1°C (98.8°F), pulse is 96/min, respirations are 21/min, and blood pressure is 150/80 mm Hg. Auscultation of the heart shows a grade 4/6 systolic murmur over the right second intercostal space that radiates to the carotids. Laboratory studies show: Leukocyte count 9,000/mm3 Hemoglobin 8.3 g/dL Hematocrit 24% Platelet count 180,000/mm3 LDH 212 U/L Haptoglobin 15 mg/dL (N=41–165) Serum Na+ 138 mEq/L K+ 4.5 mEq/L CL- 102 mEq/L HCO3- 24 mEq/L Urea nitrogen 20 mg/dL Creatinine 1.2 mg/dL Total bilirubin 1.8 mg/dL Stool testing for occult blood is negative. Direct Coombs test is negative. Echocardiography shows an aortic jet velocity of 4.2 m/s and a mean pressure gradient of 46 mm Hg. Which of the following is the most appropriate next step in management to treat this patient's anemia?

Administration of corticosteroids

A 69-year-old man is brought to the emergency room by his wife 30 minutes after losing consciousness while they were working in their garden together. The patient says that time seemed to slow down, his vision went dark, and he had a sensation of falling. After 3–5 seconds, he awoke slightly disoriented but quickly regained his baseline mental status. The patient says he has had a few similar episodes that occurred 1–2 months ago for which he did not seek any medical treatment. He says overall he has been more tired than usual and feeling out of breath on his morning walks. He denies any chest pain or palpitations. Past medical history is significant for type 1 diabetes mellitus. Current medications are atorvastatin and insulin. His family history is significant for his father who died of myocardial infarction in his 70’s. His blood pressure is 110/85 mm Hg and pulse is 82/min. On physical examination, there is a 3/6 systolic murmur best heard over the right sternal border with radiation to the carotids. S1 is normal but there is a soft unsplit S2. The lungs are clear to auscultation bilaterally. The remainder of the exam is unremarkable. Which of the following physical exam findings would also most likely be present in this patient?

A slow-rising and delayed upstroke of the carotid pulse

A decrease in systolic blood pressure ≥ 10 mmHg during inspiration

Increased capillary pulsations of the fingertips

Aortic diseases for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Aortic Aneurysm - Ballooning Big Arteries

Permanent, localized dilation of an artery (≥1.5x normal diameter). Most are abdominal aortic aneurysms (AAA).
Risk Factors: Atherosclerosis is primary. 📌 SMASH: Smoking, Male, Age >60, family hiStory, Hypertension.
Clinical: Mostly asymptomatic. Rupture triad: severe pain (back/abdominal), hypotension, pulsatile abdominal mass.
Diagnosis: Ultrasound is best for screening/monitoring. CT with contrast for symptomatic patients or pre-op planning.

CT: Abdominal Aortic Aneurysm with Mural Thrombus

Management:
- Surveillance (ultrasound) for asymptomatic AAAs < 5.5 cm.
- Elective repair (endovascular or open) if > 5.5 cm, rapid expansion (>0.5 cm in 6 mo), or symptomatic.

⭐ USPSTF Screening: One-time ultrasound for men aged 65-75 who have ever smoked.

Aortic Dissection - The Great Tear-Up

Patho: Tear in aortic intima → blood tracks into media, creating a false lumen.
Risk Factors: 📌 SOAP B - Syphilis, Old age, Atherosclerosis, Pregnancy/Polycystic kidney disease, Bicuspid aortic valve, Marfan/Ehlers-Danlos, Trauma, Cocaine.
Presentation: Sudden, tearing/ripping chest pain radiating to the back. Asymmetric BPs (>20 mmHg difference) or pulses.

⭐ Pearl: A new diastolic murmur (aortic regurgitation) is a grave sign, often indicating Type A dissection involving the aortic valve.

Stanford A and B Aortic Dissection Classification

Management

Aortitis & Acute Syndromes - Aorta's Angry Wall

Aortitis: Inflammation of the aortic wall, often leading to aneurysm or stenosis.
- Causes:
  - Large-Vessel Vasculitis: Giant Cell Arteritis (age >50), Takayasu Arteritis (age <50).
  - Infectious: Syphilitic aortitis (obliterative endarteritis of vasa vasorum → "tree bark" intima), TB.
Acute Aortic Syndromes (AAS): Life-threatening emergencies with similar presentations.
- Spectrum: Aortic Dissection (AD), Intramural Hematoma (IMH), Penetrating Atherosclerotic Ulcer (PAU).
- Classic Sx: Sudden, severe, "tearing" chest pain radiating to the back.
- Exam: Asymmetric BPs (>20 mmHg difference) or pulse deficits.
- Dx: CT Angiography is the primary imaging modality.

⭐ Chronic hypertension is the most significant risk factor for aortic dissection, present in over 75% of patients.

Acute Aortic Syndromes: Dissection, Hematoma, Ulcer

High-Yield Points - ⚡ Biggest Takeaways

Aortic dissection presents with sudden, tearing chest pain radiating to the back.

Stanford Type A dissections are a surgical emergency; Type B is often managed medically.

Marfan and Ehlers-Danlos syndromes are key risk factors in younger patients.

Abdominal Aortic Aneurysm (AAA) is often asymptomatic; look for a pulsatile abdominal mass.

Screen for AAA in men 65-75 with a smoking history via ultrasound.

Syphilitic aortitis causes a "tree-bark" appearance and can lead to aneurysms.

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Aortic diseases