Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management

Table of Contents

 

About This Issue

Acute aortic syndromes (AAS), including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer, have many different presentations and an extensive differential, including chest pain, back pain, abdominal pain, and syncope. This issue presents the critical elements of the patient’s history, physical examination, and risk factors to quickly diagnose and treat AAS. This issue discusses:

The differences in categorization between ascending, descending, categories, types, and classes of aortic dissection – and why they matter.

How the nature of the pain: chest, back, migrating, radiating, “tearing,” or “ripping” can point to what the location may be, and how often pain can be misleading or absent.

The reasons why connective tissue disorders such as Marfan, Ehlers-Danlos, and Loeys-Dietz syndromes increase the risk factors for AAS.

The urgency of managing the “chest pain plus” patients.

X-ray, CT, MRI, echocardiography: when each should be used.

How to use the Aortic Dissection Detection Risk Score (ADD-RS) and how D-dimer fits into the risk stratification picture.

Strategies for managing blood pressure and heart rate.

When emergent operative intervention is needed.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal Of the Literature
6. Pathophysiology
   1. Acute Aortic Syndromes
   2. Acute Aortic Dissection
7. Etiology
   1. Connective Tissue Disorders
   2. Intramural Hematoma
   3. Penetrating Atherosclerotic Ulcer
8. Differential Diagnosis
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Risk Stratification
11. Diagnostic Studies
    1. General Evaluation
    2. D-dimer
    3. Electrocardiogram
    4. Imaging Studies
       1. Chest Radiography
       2. Echocardiography
       3. Computed Tomographic Imaging
       4. Magnetic Resonance Imaging
       5. Aortography/Angiography
12. Treatment
    1. Management of Hemodynamic Parameters
       1. Pharmacologic Agents for Managing Hemodynamic Parameters
    2. Management of Patients in Shock
    3. Indications for Operative Intervention
       1. Ascending Type A Dissections
       2. Descending Type B Dissections
    4. Endovascular Approaches
    5. Considerations for Management of Penetrating Atherosclerotic Ulcer and Intramural Hematoma
       1. Penetrating Atherosclerotic Ulcers
       2. Intramural Hematomas
    6. Management in the Presence of Malperfusion Syndromes
13. Disposition
14. Special Circumstances
    1. Chronic Dissections
    2. Aortic Syndromes During Pregnancy
15. Controversies and Cutting Edge
    1. Detection
    2. Novel Biomarkers
    3. Contrast Imaging
16. Summary
17. Time- and Cost-Effective Strategies
18. Risk Management Pitfalls for Acute Aortic Syndromes in the Emergency Department
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for Management of Suspected Acute Aortic Syndromes in Unstable Patients
    2. Clinical Pathway for Management of Suspected Acute Aortic Syndromes in Stable Patients
21. Tables and Figures
    1. Table 1. Comparison of the DeBakey, Stanford, and Svensson Classification Systems of Aortic Dissection
    2. Table 2. Chief Complaints That Include Acute Aortic Syndromes in the Differential Diagnosis
    3. Table 3. Occurrence of Examination Findings in Aortic Dissection
    4. Table 4. Drug Therapies for Emergency Department Management of Aortic Dissection
    5. Figure 1. Pathophysiology of Aortic Dissection
    6. Figure 2. DeBakey and Stanford Classifications of Aortic Dissection
    7. Figure 3. Type A Aortic Dissection on CT
    8. Figure 4. Type B Aortic Dissection on CT
    9. Figure 5. Intramural Hematoma on CT
    10. Figure 6. Intramural Hematoma on MRI
    11. Figure 7. Penetrating Atherosclerotic Ulcer on CT
    12. Figure 8. Transesophageal Echocardiogram of Acute Type A Dissection
22. References

Abstract

Acute aortic syndromes include aortic dissection, penetrating atherosclerotic ulcer, and intramural hematomas, but aortic dissection is the most common and the deadliest. This review summarizes the latest evidence on developing a differential for aortic dissection when common complaints, such as chest pain, abdominal pain, and syncope are also present. Recent evidence on the optimal uses of emergency department imaging studies and risk stratification tools are reviewed, along with special considerations in the management of penetrating atherosclerotic ulcer and intramural hematoma. Pharmacologic therapies for managing hemodynamic parameters and shock, and indications for operative intervention are also reviewed, along with cutting-edge diagnostic and treatment options on the horizon.

Case Presentations

EMS presents with a 35-year-old man with acute chest pain that started after using cocaine…

• In addition to chest pain, he reports acute right arm weakness and numbness.
• His heart rate is 120 beats/min and his blood pressure is 220/110 mm Hg.
• While considering the options for blood pressure control, you wonder: if the head CT is negative and the blood pressure is below 180/90 mm Hg, should he be thrombolysed for an acute stroke?

A 55-year-old man presents with “tearing” chest pain, blood pressure of 240/100 mm Hg, and generalized abdominal pain…

• He has a pertinent past medical history of hypertension and was a heavy smoker for 20 years.
• He has mild epigastric tenderness and an otherwise unremarkable exam.
• Based on history, you wonder what the most appropriate workup and imaging for this patient would be…

A 48-year-old woman with Marfan syndrome is brought to the ED after a syncopal episode…

• As you are evaluating her, she rapidly becomes more ill appearing and slower to respond to verbal commands.
• Her heart rate is 140 beats/min and her blood pressure is 86/60 mm Hg. A portable chest x-ray demonstrates a widened mediastinal contour.
• What is the reliability of this radiographic film finding? If a dissection is suspected, what can be done to temporize this patient’s condition?

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Clinical Pathway for Management of Suspected Acute Aortic Syndromes in Stable Patients

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Diercks DB, Promes SB, Schuur JD, 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):32-42. (ACEP clinical policy) DOI: 10.1016/j.annemergmed.2014.11.002

7. * 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. (Retrospective; 464 patients) DOI: 10.1001/jama.283.7.897

32. * Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation. 2011;123(20):2213-2218. (IRAD registry; 2538 patients) DOI: 10.1161/CIRCULATIONAHA.110.988568

35. * Bima P, Pivetta E, Nazerian P, et al. Systematic review of aortic dissection detection risk score plus D-dimer for diagnostic rule-out of suspected acute aortic syndromes. Acad Emerg Med. 2020;27(10):1013-1027. (Retrospective; 3804 patients) DOI: 10.1111/acem.13969

59. * Nakai C, Izumi S, Haraguchi T, et al. Long-term outcomes after controlled pericardial drainage for acute type A aortic dissection. Ann Thorac Surg. 2020;110(4):1357-1363. (Retrospective cohort; 308 patients) DOI: 10.1016/j.athoracsur.2020.01.078

62. * Ahmed Y, Houben IB, Figueroa CA, et al. Endovascular ascending aortic repair in type A dissection: a systematic review. J Card Surg. 2021;36(1):268-279. (Systematic review, meta-analysis; 31 articles, 92 patients) DOI: 10.1111/jocs.15192

69. * Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC Cardiovasc Interv. 2013;6(8):876-882. (Retrospective; 1129 patients) DOI: 10.1016/j.jcin.2013.05.003

79. * Goldberg JB, Lansman SL, Kai M, et al. Malperfusion in type A dissection: consider reperfusion first. Semin Thorac Cardiovasc Surg. 2017;29(2):181-185. (Review) DOI: 10.1053/j.semtcvs.2016.10.017

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Keywords: aortic syndromes, dissection, aortic hematoma, penetrating atherosclerotic ulcer, Marfan, Ehler-Danlos, thoracic, Stanford, DeBakey, hypertension, syncope, ADD-RS, D-dimer, TEE, TTE, beta blocker, calcium-channel blocker, vasodilator, TEVAR, contrast