Aortic Dissection (AD), is uncommon (1:980 non-traumatic chest pain) but is…Rapidly FATAL! However, is testable for 80% if recognised early, unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%.
Recognition
Sudden pain [85%] – site varies and could be one or more sites; jaw, head, chest, back, abdomen pain
Migrating pain [20%] (as the flap extends)
Signs of organ injury (e.g. MI, Stroke, Abdo pain)
Pulse deficit [15-30%]
NEW Aortic Regurge [12-44%]
Cardiac Tamponade
Shock/Collapse
Investigations
CT: Diagnostic and is the test of choice [however, early dissections can be missed]
Troponin: Can be elevated
D-Dimer: useful in conjunction to low risk ADD-RS [can normalise >24hr]
ECG: May show Myocardial Infarction (MI)
Ultrasound: May show tamponade, or intimal flap
CXR: May show wide mediastinum – BUT is a not a reliable rule out!
ADD-RS
ESC 2024 recommended actions
- High Risk – ADD-RS ≥2 points = Proceed to CTA
- Moderate Risk – ADD-RS 1 point & +ve D-Dimer = Proceed to CTA
- Low Risk – ADD-RS ≤1 point & -ve D-Dimer = Consider other diagnosis
*Evidence suggests we can use Age-Adjusted D-Dimer although not validated with ADD-RS – review, and that after 24hrs D-Dimer is unreliable
Treatment
There are 3 types of dissection; A – Involving the Ascending or Arch, B – Only involving descending, Intramural Haematoma – theres blood in the wall but no flap or flow seen. ALL 3 are emergencies and from our point of view they are ALL treated the same.
- REFER to Cardio-Thoracic surgeons [Leeds] – Ensure images have been linked
- Reduce sheering stress on the aorta
- Blood Pressure and Heart Rate control – IV Labetalol
- SBP 100-120mmHg
- HR 60bpm
- Pain Control – Opiates
- Blood Pressure and Heart Rate control – IV Labetalol
The surgical management varies depending on, the type and clinical features (e.g. open surgery, endovascular, conservative). However, this needs to be the decision of the Cardio-Thoracic Team, and they should inform you of their plan (e.g. blue light transfer or manage medically on CCU).
Cardiac Tamponade
This is a complication of aortic dissection esp. type A, but its management has been controversial. Older studies having shown increased mortality with pericardiocentesis. However, the European Society of Cardiology 2024 recommended that “controlled pericardial drainage” may be a useful bridge to surgery(only removing enough blood to maintain an SBP of 90mmHg), in those too unstable to survive transfer to theatre. Practical guide from ESC HERE.
Diagnostic Strategies
There is currently no single investigation strategy and judgment plays a key role current if as recommended by some we CTA all patients with any risk factor in ADD-RS it would represent a massive burden on resource. Whereas using validated systems like ESC we can target resource more effectively. However, no stratergy is perfect clinical judgment is vital and falls into RCEM senior sign-off
|
Sign/Symptom |
Negative Likelihood Ratio |
Positive Likelihood Ratio |
|---|---|---|
|
Abrupt Onset Pain |
0.07 |
2.48 |
|
Pain Resolving |
0.88 |
1.12 |
|
Chest Pain |
0.58 |
1.49 |
|
Back Pain |
0.83 |
2.32 |
|
Migrating/Radiating Pain |
0.41 |
1.88 |
|
Subjective Neurological Deficit |
0.78 |
3.54 |
|
Differential BP >20mmHg |
0.81 |
2.19 |
|
New Murmur |
0.81 |
9.41 |
|
Pulse Deficit |
0.8 |
31.14 |
|
Widened Mediastinum CXR |
0.5 |
10.23 |
Not having abrupt onset pain dramatically reduces the risk of AD (-LR <0.1 are clincally significant), where as having a new murmur, widened mediastinum and especially a pulse deficit significantly increase your risk of AD
Ohle et al. Clinical features of acute aortic dissection. Acad Emerg Med 2018;25: 378-87
References
- Improving outcomes in acute aortic dissection – Bristol Royal inf.
- European Society of Cardiology – 2024 ESC Guidelines for the diagnosis and management of pericardial diseases
- RCEM Guide
