EM · Aortic dissection
Aortic dissection
Also known as Acute aortic dissection · Stanford Type A dissection · Acute aortic syndrome
Acute aortic dissection — intimal tear and the propagating false lumen, the Stanford/DeBakey classification, the sudden tearing migrating pain, the aortic dissection detection risk score (ADD-RS), the beta-blocker-first haemodynamic sequence with heart-rate and blood-pressure targets, surgery for Type A and medical-or-TEVAR for Type B, malperfusion syndromes, and the dissection-into-the-right-coronary-ostium trap. ACEM-primary, globally tagged.
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Pain that is sudden, maximal at onset, and tearing or ripping and migrating — distinct from the crescendo of ACS
- A blood-pressure or pulse differential greater than 20 mmHg between arms
- An inferior STEMI with a widened mediastinum — dissection into the right coronary ostium; do not thrombolyse until dissection is excluded
- A beta-blocker must be given before any vasodilator — a naked vasodilator causes reflex tachycardia that propagates the dissection
- A normal chest radiograph does not exclude dissection — normal in 12.4 per cent in IRAD
- Hypotension, a new murmur, and a widened mediastinum in the same patient is Type A dissection with tamponade until proven otherwise
Meet the patient
A 67-year-old hypertensive man arrives with sudden, tearing chest pain radiating to the interscapular area, maximal at the moment of onset and unlike any pain he has known. His right-arm blood pressure is 168 and his left is 142, and the registrar is about to reach for aspirin and a P2Y12 inhibitor because the ECG shows ST elevation in II, III and aVF. The widened mediastinum on the chest film and the 26 mmHg arm differential are the two findings that stop a fatal assumption.[1]
Two questions decide his next hour and every dissection: is the ascending aorta involved? (Stanford A is surgery) and am I about to give an antithrombotic to a dissection? Hold those two and the disease becomes manageable.[1]
References10ShowHide
- [1]Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease JAMA, 2000.PMID 10685714
- [2]Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines J Thorac Cardiovasc Surg, 2023.PMID 37389507
- [3]Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial Circ Cardiovasc Interv, 2013.PMID 23922146
- [4]Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection Circulation, 2011.PMID 21555704
- [5]Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial Eur J Vasc Endovasc Surg, 2014.PMID 24962744
- [6]Elliott WJ. Clinical features in the management of selected hypertensive emergencies Prog Cardiovasc Dis, 2006.PMID 16627047
- [7]Khan NN, Zurayyir EJ, Alghamdi AM, et al. Management strategies for hypertensive crisis: a systematic review Cureus, 2024.PMID 39262522
- [8]Teurneau-Hermansson K, Ede J, Larsson M, et al. Mortality after non-surgically treated acute type A aortic dissection is higher than previously reported Eur J Cardiothorac Surg, 2024.PMID 38310329
- [9]Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: a comprehensive emergency medicine and echocardiography review Am J Emerg Med, 2022.PMID 35696801
- [10]Heijmen R, Fattori R, Thompson M, et al.; VIRTUE Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry Eur J Vasc Endovasc Surg, 2014.PMID 24952999