Clinical introduction A 49-year-old man presented to the emergency department following sudden onset chest pain with collapse. He was refurbishing his home when he collapsed on the floor with chest and abdominal pain. He awoke 1 hour later and called the emergency services due to persisting chest discomfort that worsened with inspiration. On arrival in the emergency department, his pulse was thready (88/58 mm Hg) with pulsus paradoxus on inspiration. High-sensitivity troponin I was elevated at 325 ng/L (normal range 1–34 ng/L). Fluid resuscitation was administered and contrast-enhanced CT imaging was performed. (Figure 1).

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Figure 1

(A) CT angiogram with multiplanar reconstructions in three-chamber and axial views. (B) 12-lead ECG.

Question Which of the following best explains this presentation?

A. Type A aortic intramural haematoma

B. Left ventricular diverticulum rupture

C. Malignant pericardial effusion

D. Left ventricular pseudoaneurysm

E. Blunt cardiac trauma