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.
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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
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the December 2021 issue of Emergency Medicine Practice: Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management
The ADD-RS rules out aortic dissection
The Aortic Dissection Detection Risk Score (ADD-RS) should be used for low- to moderate-risk patients for whom acute aortic syndromes (AAS) are in the differential diagnosis. This tool, used in combination with a D-dimer test, has been proposed and internally validated as a diagnostic algorithm. There are significant caveats to the tool, including the following:
The ADD-RS may reduce misdiagnosis and overtesting for AAS, thereby avoiding unnecessary radiation exposure and the cost associated with definitive imaging. Consider using this risk stratification algorithm in patients who are at low risk for aortic dissection but for whom the diagnosis cannot be ruled out. The ADD-RS has a scoring range of 0 to 3; patients can be given just 1 point for each category (predisposing conditions, pain features, and exam findings). Thus, the score does not account for a patient who meets multiple criteria within a category. Patients meeting multiple criteria in a given category may not be appropriate candidates for the algorithm.
In 2010, the American Heart Association and the American College of Cardiology released guidelines for the diagnosis and management of AAS, including a set of 12 clinical markers of the disease. Rogers et al (2011) used retrospective data from the International Registry of Acute Aortic Dissection to validate the sensitivity of these markers. Among 2538 patients with acute aortic dissection, 2430 patients (95.7%) were identified by 1 or more of the 12 proposed clinical risk markers.
The International Registry of Acute Aortic Dissection investigators (Suzuki 2009) also performed a prospective multicenter study of 220 patients with initial suspicion for acute aortic dissection. Eighty-seven of those patients were ultimately diagnosed with acute aortic dissection. The widely used D-dimer cutoff of <500 ng/mL showed promise for ruling out AAS, with a negative likelihood ratio of 0.07 through the first 24 hours and a sensitivity of 96.6%.
The authors of the ADvISED trial (Nazerian 2018) designed and tested the ADD-RS/D-dimer novel clinical pathway for ruling out acute aortic dissection, combining clinical risk stratification with D-dimer as a serum biomarker. This multicenter prospective observational trial enrolled 1850 consecutive chest pain patients, 241 (13%) of whom were diagnosed with AAS. An ADD-RS score of ≤1 and a negative D-dimer result demonstrated a sensitivity of 98.8%, a negative predictive value of 99.7%, and a negative likelihood ratio of 0.02. The shortcomings of this study included the following:
Peiman Nazerian, MD
Anthony Hackett, DO, FACEP, FAAEM, FRSM; Jonathan Stuart, DO, MS; Douglas L. Robinson, DO, MS
Daniel Eraso, MD; Trevor Pour, MD
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Cover image: Surface-shaded CT of Stanford type B aortic dissection.