submitted by Christina Brown, M.D.
Definition – Blood entering intimal tear in aortic wall. Blood subsequently dissects through the media under aortic systolic pressure.
Risk Factors – HTN, Tobacco abuse, pregnancy, congenital heart disease (bicuspid AV, Coarctation), Marfan’s, Ehler’s Danlos, Inflammation (Lupus, syphilis, endocarditis, GCA)
Proximal – Occur at the aortic root, coronary ostia and/or pericardium.
Distal – Dissect distally to involve any or all branches of the aorta ie -carotid and subclavian arteries.
- Type A: Ascending aorta
- Type B: Distal to ascending aorta
Peak Age for Occurrence
- Proximal dissection: 50–55 yr
- Distal dissection: 60–70 yr
- Occlusion of the coronary ostia, aortic valve incompetence, or cardiac tamponade.
Signs & Symptoms
- May be absent in as many as 15% of patients
- Acute onset, sharp
- Substernal -> type A dissection
- Intrascapular -> descending thoracic dissection
- Lumbar -> abdominal aorta involvement
- Commonly interscapular or lumbar. May present as combination of chest, back, and abdominal pain.
Neurologic complaints: Stroke symptoms, Vision changes
Hypertension: 35–40% may be normotensive.
Pulse deficits: Discrepancies in BP in upper extremities
Neurologic/spinal cord deficits
New murmur of aortic regurgitation: Occurs in up to 31% of patients
EKG – Dissection may involve coronary ostia and cause MI:
- Inferior MI (RCA territory) is more common than LCA territory.
- A normal EKG + severe, acute-onset chest/back pain/shortness of breath – high suspicion for aortic dissection.
- CBC, BMP, UA – Evaluate renal function, hematuria
- Amylase – May be elevated d/t bowel ischemia
- Troponin – May be elevated d/t myocardial ischemia
CXR – Widened mediastinum or abnormal aortic contour.
Echocardiogram – Transthoracic vs Transoesophageal (if intubated) – Tamponade, valvular incompetence for evaluation.
Stable Patient: CT, Aortography
BP Control = Reduce shear force on aortic wall and slow down the dissection process.
- Esmolol (IV) or labetalol (IV): Start before Nitroprusside therapy to prevent reflex tachycardia.
- Contraindications:Bradycardia, COPD, hypotension
- Treatment of choice for type A dissection
- Treatment for type B dissections in those who have failed medical therapy
- Treatment of choice for stable type B dissections
ADMIT – All patients with an evolving aortic dissection should be admitted to the ICU. C/S cardiothoracic surgery for type A dissection.
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