Acute tearing chest or interscapular pain
Recommended: CT Angiogram chest/abdomen/pelvis is the preferred imaging study for acute tearing chest or interscapular pain. ECG-gated protocol preferred when available.
Recommended study
CT Angiogram chest/abdomen/pelvis
ECG-gated protocol preferred when available. TEE is an alternative when iodinated contrast is contraindicated.
If the default doesn't apply
Iodinated contrast contraindicated, hemodynamically stable
US
TEE
No contrast
Pregnancy, stable
MRI
MRA chest/abdomen/pelvis
IV contrast
Watch-outs
Hemodynamic instability
Bedside TTE first to assess for tamponade / proximal flap; do not delay surgery for confirmatory CTA.
Type A on imaging
Surgical emergency — directly to OR. Type B managed medically unless complicated.
D-dimer can help triage
Negative high-sensitivity d-dimer + ADD score 0–1 has high negative predictive value, but does not replace imaging when suspicion is moderate-high.
Pearls
- Use the AAS / ADD risk score to risk-stratify before imaging.
- ECG-gated CTA reduces motion artifact at the aortic root — critical for ascending aorta evaluation.
- Mortality increases ~1% per hour in Type A — do not delay the scan.