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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

HOSPITALIZATION CRITERIA

  • Suspected aortic dissection

  • Hypotension, shock

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