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A young man with sudden onset persistent chest pain

A man in his 30s presented to the emergency department with sudden onset chest pain lasting for six hours. His pain was greatest at onset and he described it as an intense pressure radiating to the back. The pain did not relate to inspiration. He also experienced a transient loss of consciousness, and reportednoprevious episodes of chest pain or history of hypertension or diabetes. During physical examination, pulse asymmetry (weaker on the left) was observed, along with radio-radial delay . His blood pressure was 156/108 mm Hg in the right arm and 115/71 mm Hg in the left. His oxygen saturation was 98% in roomair. Echocardiography showedwall motion abnormalities, and left ventricular ejection fraction was 39%. The structure of the aortic valve was normal. Laboratory investigations were made, which showed his troponin level was elevated. Electrocardiogram (ECG) and contrast enhanced chest computed tomographic angiography (CTA) images are shown in figure 1.