Acute Aortic Syndromes: Diagnose the Catastrophe
Scope
- Acute aortic syndromes include:
- Aortic dissection
- Intramural hematoma
- Penetrating aortic ulcer
When to Suspect Acute Aortic Syndrome
- Consider acute aortic syndrome in patients with chest, back, or abdominal pain that is:
- Abrupt and severe
- Maximal at onset
- Migrating
- Tearing, ripping, sharp, or otherwise described as different from prior pain
- Pair the pain history with high-risk findings:
- Pulse deficits
- New diastolic murmur
- Syncope
- Neurologic deficits
- ECG changes
- Normal blood pressure does not exclude type A dissection.
Diagnostic Approach
- CT angiography is the diagnostic test of choice.
- Use bedside transesophageal echocardiography when instability makes CT impractical.
- D-dimer-based decision rules are an adjunct only for selected low-risk patients.
- The literature does not support routine rule-out use.
- When suspicion is high:
- Do not delay transfer solely to obtain every imaging plane.
- A noncontrast CT demonstrating aortic enlargement with a convincing clinical presentation should accelerate transfer to an aortic surgery center.
Initial Anti-Impulse Treatment
- Begin anti-impulse treatment while arranging definitive care.
- Target systolic blood pressure: 100 to 120 mmHg.
- Use intravenous beta blockade first:
- Labetalol
- Esmolol
- Add nicardipine if further blood pressure reduction is required.
- Give nitroprusside only after beta blockade because reflex tachycardia can increase aortic stress.
- Provide analgesia to reduce sympathetic drive.
- Establish large-bore intravenous access and monitor the patient.
Definitive Management
- Type A disease:
- Involves the ascending aorta.
- Requires emergency surgical management.
- Type B disease:
- Involves the descending aorta.
- Is managed medically unless complications develop.
- Complications include malperfusion, rupture, or rapid expansion.
High-Risk Errors to Avoid
- Do not treat suspected acute coronary syndrome with anticoagulation or thrombolysis before excluding dissection.
- Do not be reassured by stable vital signs.
- Do not route a likely type A patient through a nonsurgical hospital.
Summary Takeaway
The essential sequence is early recognition, controlled impulse reduction, and rapid specialist transfer.
