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 | ||
***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 | ||
{| | {| 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: | |- 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;" | ||
||'''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;" | ||
||'''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) | ||
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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 | **Voice hoarseness - recurrent laryngeal nerve compression | ||
**CVA/[[Syncope]] - if carotid extension | **CVA/[[Syncope]] - if carotid extension | ||
**Neurological deficits | **Neurological deficits | ||
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**Focal neuological deficit (in conjunction with pain) | **Focal neuological deficit (in conjunction with pain) | ||
*Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain) | *Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain) | ||
*Hypotension of shock state | *[[Hypotension]] of shock state | ||
|} | |} | ||
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*[[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 | ===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]] for ADD score ≤ 1 (low or intermediate risk) | |||
* | |||
===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== | ||
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**Right radial arterial line or right arm blood pressure will be the most accurate | **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 | **Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension | ||
**However, avoid | ***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 | #*[[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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**[[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
- Connective tissue disease (e.g. Marfan syndrome, Ehler's-Danlos, collagen vascular disease)
- Pregnancy, especially 3rd trimester
- Recent cardiac catheterization
- Bicuspid aortic valve
- Aortic coarctation
- Elderly males with chronic hypertension
- Atherosclerotic risk factors (smoking, hypertension, HLD, DM)
- Young with risk factors
Classification (Stanford)
- Type A - Involves any portion of ascending aorta
- Requires surgery
- Type B - Isolated to descending aorta
- Primarily medical management with surgery consultation
Image | |||
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
- Chest pain, back pain, abdominal pain
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
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 |
|
Chest, back, or abdominal pain described as:
AND
|
|
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
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
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]
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
- However, avoid β-blockers in aortic regurgitation murmurs or on bedside echo
- 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
- Esmolol
- 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
- Analgesia
Disposition
- Admission to OR or ICU
Complications
- AV Regurgitation/Insufficiency
- CHF with diastolic murmur
- Rupture
- Pericardium: cardiac tamponade
- Mediastinum: hemothorax
- Vascular obstruction
See Also
External Links
- NNT Aortic Dissection LRs
- AHA Full Guidelines
- AHA Quick Summary
- ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)
- MDcalc ADD Score
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.
- ↑ 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.
- ↑ http://www.thepocusatlas.com/echocardiography-1
- ↑ Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf