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Home | Articles | Cardiac | Aortic Dissection

Aortic Dissection

Last updated 19th March 2024

Introduction

  1. Rare but important cause of central chest discomfort that may be difficult to distinguish from ACS and submassive PE
  2. Type A if dissection involves ascending aorta regardless of origin
  3. Type B if dissection involves only the descending thoracic aorta regardless of origin
  4. Mortality may be as high as 50% for patients with Type A dissection who are shocked at presentation

High Risk Features in Past History

  1. Marfan syndrome
  2. Connective tissue diseases
  3. Family history of aortic disease
  4. Known aortic valve disease
  5. Recent aortic manipulation
  6. Known thoracic aortic aneurysm

High Risk Features of Chest Pain

  1. Abrupt in onset
  2. Radiation to back
  3. Severe in intensity
  4. Ripping or tearing in quality
  5. Patients can also present with pleuritic chest pain ?PE

High Risk Features on Examination

  1. Inequality of radial pulses
  2. Blood pressure difference in arms
  3. Focal neurologic deficit (in conjunction with pain)
  4. Murmur of aortic regurgitation (new and in conjunction with pain)
  5. Hypertensive but looks shocked

Investigations and Diagnosis

  1. ECG to exclude ACS
  2. CXR may show widened mediastinum
  3. D-dimer: a normal result means AD highly unlikely
  4. CT aorta is definitive
  5. We now use double gated CTPA which means that patients will have their AD detected even if they were initially thought to have PE
  6. Click to access MD Calc Aortic Dissection Detection Risk Score which allows you to rule out AD with a NPV of 99.7% in a patient with no high risk features, e.g. Marfan Syndrome, and a D-dimer <500

Management

  1. Move to Critical Care
  2. Pain control with morphine
  3. BP control with IV labetalol (Click here for Hypertensive Emergencies page) 10mg IV bonus every 10 mins to max 200mg then IV infusion 15mg/hour aiming for SBP 100-120mmHg and HR 50-60/min
  4. Type A dissection – phone Golden Jubilee 0141 951 5000 and ask for on-call Cardiothoracic Surgeon
  5. Type B dissection – phone Hairmyres 01355 585000 and ask for on-call Vascular Surgeon

Links

Think Dissection – Management of Acute Type B Aortic Dissections [pdf] – Produced by NHS Lothian

Content Updated by Chris Isles