Nontraumatic thoracic aortic dissection: Difference between revisions

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*Bimodal age distribution
*Bimodal age distribution
**Young with risk factors
**Young with risk factors
***[[Connective tissue disease]] (e.g. [[Marfan syndrome]], Ehler's-Danlos, collagen vascular disease
***[[Connective tissue disease]] (e.g. [[Marfan syndrome]], Ehler's-Danlos, collagen vascular disease)
***Pregnancy, especially 3rd trimester
***Pregnancy, especially 3rd trimester
***[[Chest trauma]]
***Recent cardiac catheterization
***Recent cardiac catheterization
***Bicuspid aortic valve
***Bicuspid aortic valve
***Aortic coarctation
***[[coarctation of the Aorta|Aortic coarctation]]
**Elderly males with chronic hypertension
**Elderly males with chronic hypertension
**Atherosclerotic risk factors (smoking, hypertension, HLD, DM)
**Atherosclerotic risk factors (smoking, hypertension, HLD, DM)
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**Primarily medical management with surgery consultation
**Primarily medical management with surgery consultation


{| border="1" cellspacing="0" style="width:320px;float:right;margin-left:0.5em;border-collapse:collapse"
{| class="wikitable"
|+Classification of aortic dissection
|+Classification of aortic dissection
|-
|- style="background:white;"
|valign="top"|
|valign="top"|'''Image'''
|[[File:AoDissect DeBakey1.png|90px]]
|[[File:AoDissect DeBakey1.png|90px]]
|[[File:AoDissect DeBakey2.png|90px]]
|[[File:AoDissect DeBakey2.png|90px]]
|[[File:AoDissect DeBakey3.png|90px]]
|[[File:AoDissect DeBakey3.png|90px]]
|- style="background:#dcdcdc;"
|- style="background:white;"
||Percentage
||'''Percentage'''
|  style="text-align:center; "|60%
|  style="text-align:center; "|60%
|  style="text-align:center; "|10–15%
|  style="text-align:center; "|10–15%
|  style="text-align:center; "|25–30%
|  style="text-align:center; "|25–30%
|-
|- style="background:white;"
|style="border-bottom:white"|Type
||'''Type'''
| style="text-align:center;" border="0"|DeBakey I
| style="text-align:center;" border="0"|DeBakey I
| style="text-align:center;"|DeBakey II
| style="text-align:center;"|DeBakey II
| style="text-align:center;"|DeBakey III
| style="text-align:center;"|DeBakey III
|-
|- style="background:white;"
|style="border-bottom:white"|
||'''Classification'''
| colspan=2 style="text-align:center;"|Stanford A (Proximal)
| colspan=2 style="text-align:center;"|Stanford A (Proximal)
| style="text-align:center;"|Stanford B (Distal)
| style="text-align:center;"|Stanford B (Distal)
|-
|-
|}
===Acute Aortic Dissection (AAD) Risk Score===
''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features''
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Predisposing conditions'''
| align="center" style="background:#f0f0f0;"|'''Pain features'''
| align="center" style="background:#f0f0f0;"|'''Physical findings'''
|-
|
*Marfan syndrome
*Connective tissue disease
*Family history of aortic disease
*Recent aortic manipulation
*Known thoracic aortic aneurysm
||
Chest, back, or abdominal pain described as:
*Abrupt in onset/severe in intensity
AND
*Ripping/tearing/sharp or stabbing quality
||
*Evidence of perfusion deficit
**Pulse deficit
**Systolic BP differential
**Focal neuological deficit (in conjunction with pain)
*Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
*Hypotension of shock state
|}
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Score'''
| align="center" style="background:#f0f0f0;"|'''Category'''
| align="center" style="background:#f0f0f0;"|'''Prevalence'''
|-
| 0||Low||6%
|-
| 1||Intermediate||27%
|-
| >1||High||39%
|}
|}


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*Ascending Aorta
*Ascending Aorta
**Acute [[aortic regurgitation]], leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66%  
**Acute [[aortic regurgitation]], leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66%  
**[[MI]]/Ischemia on ECG, usually inferior
**[[MI]]/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery<ref>Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.</ref>)
**[[Cardiac Tamponade]]
**[[Cardiac Tamponade]]
**[[Hemothorax]] - if adventitia disruption
**[[Hemothorax]] - if adventitia disruption
**Horners, partial - sympathetic ganglion
**Horners, partial - sympathetic ganglion
**Voice hoarseness - recurrent laryngeal n. compression
**Voice hoarseness - recurrent laryngeal nerve compression
**CVA/[[Syncope]] - if carotid extension
**CVA/[[Syncope]] - if carotid extension
**Neurological deficits
**Neurological deficits
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==Evaluation==
==Evaluation==
===Acute Aortic Dissection (AAD) Risk Score===
''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features''
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Predisposing conditions'''
| align="center" style="background:#f0f0f0;"|'''Pain features'''
| align="center" style="background:#f0f0f0;"|'''Physical findings'''
|-
|
*Marfan syndrome
*Connective tissue disease
*Family history of aortic disease
*Recent aortic manipulation
*Known thoracic aortic aneurysm
||
Chest, back, or abdominal pain described as:
*Abrupt in onset/severe in intensity
AND
*Ripping/tearing/sharp or stabbing quality
||
*Evidence of perfusion deficit
**Pulse deficit
**Systolic BP differential
**Focal neuological deficit (in conjunction with pain)
*Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
*[[Hypotension]] of shock state
|}
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Score'''
| align="center" style="background:#f0f0f0;"|'''Category'''
| align="center" style="background:#f0f0f0;"|'''Prevalence'''
|-
| 0||Low||6%
|-
| 1||Intermediate||27%
|-
| >1||High||39%
|}
===No Risk Factor Screening===
===No Risk Factor Screening===
*[[CXR]]
*[[CXR]]
**Abnormal in 90%  
**Abnormal in 90%  
**Mediastinal widening (seen in 63%)  
**Mediastinal widening (seen in 56-63%)  
**Left sided pleural effusion (seen in 19%)  
**Left sided pleural effusion (seen in 19%)  
**Widening of aortic contour, displaced calcification (6mm), aortic kinking, double density sign
**Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign
[[File:Dissection CXR.jpg|thumbnail|CXR showing widened mediastinum and porminent aortic knob]]
[[File:Dissection CXR.jpg|thumbnail|CXR showing widened mediastinum and porminent aortic knob]]


===Low AAD risk Rule-Out<ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref>===
===Low-Intermediate (Based on AAD) Risk Rule-Out<ref>Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</ref><ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref><ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>===
*[[D-dimer]]
*[[D-dimer]] for ADD score ≤ 1 (low or intermediate risk)
**May use for ADD score = 0 (post test probability <0.3%)
**Sn 0.97 and Sp 0.56 (NPV 0.96)<ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>
**ACEP considers D-dimer as Level C<ref>Diercks DB, et al. Clinical policy: Critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015; 65(1):32-42e12.</ref>


===High Risk/Definitive===
===High Risk/Definitive===
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*Bedside US
*Bedside US
**Can help in ruling in patients when AOFT is >4cm
**Can help in ruling in patients when AOFT is >4cm
**Rule out pericardial effusion and tamponade
**Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea
**TEE has a sensitivity of 98% and 95% specific<ref>Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.</ref>
**TEE has a sensitivity of 98% and 95% specific<ref>Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.</ref>
[[File:aorticdissection.gif|thumbnail|Type A Aortic Dissection<ref>http://www.thepocusatlas.com/echocardiography-1</ref>]]


==Management==
==Management==
''Lower wall tension by lowering BP (La Place T = P × r)''
''Lower wall tension by lowering BP (La Place T = P × r)''
;Control heart rate before blood pressure (Goal to keep HR 60-80 and SBP 100-120)
;Control heart rate before blood pressure (Goal to keep HR 60-80 and SBP 100-120)
*Important considerations
**Right radial arterial line or right arm blood pressure will be the most accurate
**Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension
***However, avoid β-blockers in [[aortic regurgitation]] murmurs or on bedside echo
#Heart rate control ([[beta-blockers]] are first line)
#Heart rate control ([[beta-blockers]] are first line)
#*[[Esmolol]]  
#*[[Esmolol]]  
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#**Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
#**Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
#**[http://emcrit.org/wp-content/uploads/2013/01/esmolol-drip-sheet.pdf Esmolol Drip Sheet]  
#**[http://emcrit.org/wp-content/uploads/2013/01/esmolol-drip-sheet.pdf Esmolol Drip Sheet]  
#*[[Labetalol]] - has both alpha and beta effects
#*[[Labetalol]] - has both α and beta effects
#**Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
#**Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
#**Drip - Load 15-20mg IV, followed by 5mg/hr
#**Drip - Load 15-20mg IV, followed by 5mg/hr
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#*Only use if beta-blocker is ineffective  
#*Only use if beta-blocker is ineffective  
#*Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)  
#*Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)  
#*[[Nicardipine]]/Clevidipine - consider following regimen for nicardipine:
#*[[Nicardipine]]/[[Clevidipine]] - consider following regimen for nicardipine:
#**5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal
#**5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal
#**Once at goal, drop to 3mg/hr and re-titrate from there
#**Once at goal, drop to 3mg/hr and re-titrate from there
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#Analgesia
#Analgesia
#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output
#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output
==Disposition==
*Admission to OR or ICU


==Complications==
==Complications==
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**[[CHF]] with diastolic murmur  
**[[CHF]] with diastolic murmur  
*Rupture  
*Rupture  
**Pericardium: tamponade  
**Pericardium: [[cardiac tamponade]]
**Mediastinum: hemothorax  
**Mediastinum: [[hemothorax]]
*Vascular obstruction  
*Vascular obstruction  
**Coronary: ACS  
**Coronary: [[ACS]]
**Carotid: CVA  
**Carotid: [[CVA]]
**Lumbar: Paraplegia
**Lumbar: Paraplegia


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*[http://emupdates.com/2010/06/23/accaha-aortic-dissection-guideline/ AHA Quick Summary]
*[http://emupdates.com/2010/06/23/accaha-aortic-dissection-guideline/ AHA Quick Summary]
*[http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/ ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)]
*[http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/ ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)]
*[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs#evidence MDcalc ADD Score]


==References==
==References==

Revision as of 16:39, 18 August 2019

Not to be confused with traumatic aortic transection

Background

  • Most commonly seen in men 60-80 yrs old
  • Intimal tear with blood leaking into media
  • Mortality increases 1% per hour of symptoms when untreated
  • Diagnosis delayed > 24hr in 50% of cases
  • Bimodal age distribution
    • Young with risk factors
    • Elderly males with chronic hypertension
    • Atherosclerotic risk factors (smoking, hypertension, HLD, DM)

Classification (Stanford)

  • Type A - Involves any portion of ascending aorta
    • Requires surgery
  • Type B - Isolated to descending aorta
    • Primarily medical management with surgery consultation
Classification of aortic dissection
Image AoDissect DeBakey1.png AoDissect DeBakey2.png AoDissect DeBakey3.png
Percentage 60% 10–15% 25–30%
Type DeBakey I DeBakey II DeBakey III
Classification Stanford A (Proximal) Stanford B (Distal)

Clinical Features

General

  • Symptoms
    • Tearing/ripping pain (10.8x increased disease probability)
    • Migrating pain (7.6x)
    • Sudden chest pain (2.6x)
    • History of hypertension (1.5x)
  • Signs
    • Focal neurologic deficit (33x)
    • Diastolic heart murmur (acute aortic regurg) (4.9x)
    • Pulse deficit (2.7x)
    • Hypertension at time of presentation (49% of all cases[1])
  • Studies
    • Enlarged aorta or widened mediastinum (3.4x)
    • LVH on admission ECG (3.2x)

Specific

  • Ascending Aorta
    • Acute aortic regurgitation, leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66%
    • MI/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery[2])
    • Cardiac Tamponade
    • Hemothorax - if adventitia disruption
    • Horners, partial - sympathetic ganglion
    • Voice hoarseness - recurrent laryngeal nerve compression
    • CVA/Syncope - if carotid extension
    • Neurological deficits
    • SBP>20mmhg difference between arms
    • Hypertension at time of presentation (35.7% of all cases[1])
  • Descending Aorta
    • Chest pain, back pain, abdominal pain
      • Chest Pain - Abrupt, severe (90% of patients) radiating to back
    • Hypertension at time of presentation (70.1% of all cases[1])
    • Hemiplegia, neuropathy (15%)
    • Renal failure
    • Distal Pulse deficits/ limb ischemia
    • Mesenteric ischemia

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Hypertension

Evaluation

Acute Aortic Dissection (AAD) Risk Score

A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features

Predisposing conditions Pain features Physical findings
  • Marfan syndrome
  • Connective tissue disease
  • Family history of aortic disease
  • Recent aortic manipulation
  • Known thoracic aortic aneurysm

Chest, back, or abdominal pain described as:

  • Abrupt in onset/severe in intensity

AND

  • Ripping/tearing/sharp or stabbing quality
  • Evidence of perfusion deficit
    • Pulse deficit
    • Systolic BP differential
    • Focal neuological deficit (in conjunction with pain)
  • Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
  • Hypotension of shock state
Score Category Prevalence
0 Low 6%
1 Intermediate 27%
>1 High 39%

No Risk Factor Screening

  • CXR
    • Abnormal in 90%
    • Mediastinal widening (seen in 56-63%)
    • Left sided pleural effusion (seen in 19%)
    • Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign
CXR showing widened mediastinum and porminent aortic knob

Low-Intermediate (Based on AAD) Risk Rule-Out[3][4][5]

  • D-dimer for ADD score ≤ 1 (low or intermediate risk)

High Risk/Definitive

  • CT aortogram chest
    • Study of choice
    • Similar sensitivity/specificity to TEE and MRA
CT chest with contrast of thoracic aortic dissection.

Other Findings

  • ECG
    • Ischemia (esp inferior) - 15%
    • Nonspec ST-T changes - 40%
  • Bedside US
    • Can help in ruling in patients when AOFT is >4cm
    • Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea
    • TEE has a sensitivity of 98% and 95% specific[6]
Type A Aortic Dissection[7]

Management

Lower wall tension by lowering BP (La Place T = P × r)

Control heart rate before blood pressure (Goal to keep HR 60-80 and SBP 100-120)
  • Important considerations
    • Right radial arterial line or right arm blood pressure will be the most accurate
    • Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension
  1. Heart rate control (beta-blockers are first line)
    • Esmolol
      • Advantage of short half life, easily titratable
      • Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
      • Esmolol Drip Sheet
    • Labetalol - has both α and beta effects
      • Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
      • Drip - Load 15-20mg IV, followed by 5mg/hr
    • Metoprolol
      • 5mg IV x 3; infuse at 2-5mg/hr
    • Diltiazem - Use if contraindications to beta-blockers
      • Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
  2. Blood pressure control (vasodialators)
    • Only use if beta-blocker is ineffective
    • Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)
    • Nicardipine/Clevidipine - consider following regimen for nicardipine:
      • 5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal
      • Once at goal, drop to 3mg/hr and re-titrate from there
      • May initially bolus 2mg IV[8]
    • Nitroprusside 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity
    • Fenoldopam
    • Enalapril
  3. Analgesia

Disposition

  • Admission to OR or ICU

Complications

  • AV Regurgitation/Insufficiency
    • CHF with diastolic murmur
  • Rupture
  • Vascular obstruction
    • Coronary: ACS
    • Carotid: CVA
    • Lumbar: Paraplegia

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.
  2. ↑ Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.
  3. ↑ Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.
  4. ↑ Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.
  5. ↑ Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.
  6. ↑ Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.
  7. ↑ http://www.thepocusatlas.com/echocardiography-1
  8. ↑ Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf
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