Sudden tearing chest pain radiating to the back with inter-arm blood pressure difference

A 62-year-old man with a 20-year history of poorly controlled hypertension presents to the emergency department with sudden onset of severe, sharp chest pain that began 30 minutes ago while he was watching television. The pain is described as “tearing” and radiates to his back between the shoulder blades. He is diaphoretic and anxious. Vital signs: T 36.8°C (98.2°F), BP 198/112 mm Hg in the right arm and 168/98 mm Hg in the left arm, HR 112/min, RR 22/min, SpO2 97% on room air. Physical exam shows a faint right radial pulse compared with the left. ECG shows sinus tachycardia without ST-segment changes. A bedside transthoracic echocardiogram shows a small pericardial effusion. Which of the following best describes the underlying pathologic process responsible for this patient’s condition?

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