Pauci-Symptomatic Aortic Dissection

A 61-year-old man woke up with unusual heartburn (no radiation or dyspnea) and drove himself to the Emergency Department. He looked comfortable with normal physical examination and ECG. Blood pressure was 110/60 mm/Hg (both hands), heart rate 54/min, respiratory rate 12/min, oxygen saturation 98%. He had hypertension (well-controlled on nifedipine 30 mg/atenolol 100 mg), obesity, smoked 1pack/day, and took non-steroidal anti-inflammatory drugs (NSAIDs) over 5 days for knee pain. Hb was 14.1 g/dL, white blood cell count 12.9 × 103/µL, platelets 223 × 103/µL, C-reactive protein 16.8 mg/L, blood urea nitrogen 30.3 mg/dL, creatinine 1.3 mg/dL, transaminases 103-168 IU/L, normal cholestatic enzymes, serum proteins, electrolytes, troponin (8.5 ng/L), and urinalysis.