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 Abstract

In this issue of EM Practice Guidelines Update, the recently released American College of Cardiology / American Heart Association Guidelines for the Diagnosis and Management of Thoracic Aortic Disease¹will be reviewed. The recommendations pertinent to emergency medicine focus on appropriate screening methods to help identify acute thoracic aortic dissection (AoD) and provide recommendations on diagnostic testing and early management of the disease.

Acute AoD is among the most lethal of the cardiovascular catastrophes with approximately 40% of affected patients dying immediately and 1% per hour dying thereafter.² Despite this, emergency clinicians diagnose acute AoD on initial presentation in only 15% to 43% of patients who are ultimately diagnosed with the disease.^3,4 This is due, in part, to the low prevalence of acute AoD compared to other lethal causes of chest pain, as well as the tendency of acute AoD to present with atypical features. Although there are few large trials, registry data suggest that the majority of acute AoD patients can be identified on the basis of underlying conditions, presenting symptoms, and examination findings.

Practice Guideline Impact

• Patients presenting with symptoms that could represent acute AoD should receive a diagnostic evaluation based on a bedside risk assessment focused on specific clinical criteria: conditions that predispose to acute AoD, pain characteristics that predict acute AoD, and examination features consistent with end-organ effects of acute AoD.
• When acute AoD is confirmed or the pretest probability is high, management priorities are aggressive analgesia, beta-blockade to a target heart rate of 60 beats per minute (BPM), followed by vasodilator therapy, if needed, to a target systolic blood pressure (SBP) of 100-120 mm Hg. Surgical evaluation should be promptly arranged.

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