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A 55‐year‐old man, with a history of hypertension and smoking, presented with severe acute onset central chest pain, radiating through to the back and down to the umbilicus area of the abdomen. His blood pressure was 210/110 in both arms, peripheral pulses were normal, and there was no focal neurological sign. An electrocardiogram was normal. Chest x ray did not show obvious mediastinal widening, but incidentally the space between intimal calcification and the outer border of the aortic arch was >1 cm, a recognised radiological sign of aortic dissection (fig 11).). Awareness of this is crucial. Troponin was normal but D‐dimer was raised. A computed tomography scan confirmed aortic dissection type B, managed conservatively with intravenous labetolol and analgesia, with a good outcome.