Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Acute upper chest or back pain, frequently with hemodynamic instability Various neurologic symptoms such as Horner’s syndrome, paraplegia, and stroke Absent or unequal peripheral pulses New aortic regurgitation Confirmatory aortic imaging study Widened mediastinum on chest x-ray Confirmatory aortic imaging study +++ GENERAL CONSIDERATIONS ++ Usually occurs in middle-aged or elderly hypertensive men – Occasionally occurs in young patients with history of Marfan’s syndrome or other connective tissue disorder – Rarely occurs in young women in late pregnancy or during labor Pathology usually an internal tear that permits dissection of the media to create a false and true channel May present as 1 of 2 precursors to frank dissection: intramural hematoma or penetrating aortic ulcer Usually classified into 2 types: – Type A: tear in ascending aorta usually 2–3 cm above the coronary ostia – Type B: tear in arch or, more commonly, the descending aorta 1–2 cm distal to the left subclavian artery origin Hypertension and Marfan’s syndrome are the 2 main predisposing conditions Bicuspid aortic valve and coarctation of the aorta also associated with aortic dissection +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Sudden, intense, unremitting chest or upper back pain, sometimes described as tearing Syncope may occur Paralysis may occur +++ PHYSICAL EXAM FINDINGS ++ High or low blood pressure Diminished or absent pulses possible Aortic regurgitation murmur in some Pericardial rub in a few Neurologic findings: – Horner’s syndrome – Paraplegia – Stroke +++ DIFFERENTIAL DIAGNOSIS ++ Acute myocardial infarction Angina pectoris Acute pericarditis Pneumothorax Pulmonary embolism Boerhaave’s syndrome Cerebrovascular accident Acute surgical abdomen Peripheral embolism Neurologic disease causing paraplegia, Horner’s syndrome +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ D-dimer, if negative aortic dissection highly unlikely +++ ELECTROCARDIOGRAPHY ++ Left ventricular hypertrophy may be seen if hypertensive Myocardial ischemia can occur Changes suggestive of pericarditis can occur +++ IMAGING STUDIES ++ Chest x-ray: – Widened upper mediastinum – Double shadow of aortic wall – Disparity in size of ascending and descending aorta Transthoracic echocardiography: occasionally demonstrates an ascending tear and dissection; less commonly, a descending dissection Transesophageal echocardiography: excellent for detecting dissection of the ascending and descending aorta, but less so with the arch CT and MRI angiography: excellent for detecting aortic dissection and intramural hematoma +++ DIAGNOSTIC PROCEDURES ++ Aortography is rarely used today but demonstrates penetrating aortic ulcers well Coronary arteriography may be required in some patients and is accomplished at some increase in risk +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Suspected aortic dissection Hypotension, shock Acute aortic regurgitation... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.