27 Jun

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.

Stanford classification:

  • 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

Chest Pain:

  • 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

Back pain:

  • Commonly interscapular or lumbar. May present as combination of chest, back, and abdominal pain.

Neurologic complaints: Stroke symptoms, Vision changes


Physical Exam

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



Unstable Patient:

CXR – Widened mediastinum or abnormal aortic contour.

Echocardiogram – Transthoracic vs Transoesophageal (if intubated) – Tamponade, valvular incompetence for evaluation. 

Stable Patient:  CT, Aortography


ED Treatment

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
  • Nitroprusside


Emergent surgery:

  • Treatment of choice for type A dissection
  • Treatment for type B dissections in those who have failed medical therapy

Medical management:

  • 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.



1] Jeffrey I. Schneider and Jonathan S. Olshaker.  Aortic Dissection, Thoracic. Rosen & Barkin’s 5-minute Emergency Medicine Consult.
2] Erbel R, Alfonso F, and Boileau C et al.: Diagnosis and management of aortic dissection. Eur Heart J. 2001; 22(18):1642–1681. [PMID: 11511117]
[3] Hagan P G, Nienaber C A, and Isselbacher E M et al.: The international registry of acute aortic dissection: New insights into an old disease. JAMA. 2000; 283(7):897–903. [PMID:10685714]
[4] Khan I A and Nair C K.: Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002; 122(1):311–328. [PMID: 12114376]
[5] Klompas M.: Does this patient have an acute thoracic aortic dissection? JAMA. 2002; 287:2262–2272. [PMID: 11980527]
[6] Mészáros I, Mόrocz J, and Szlávi J et al.: Epidemiology and clinicopathology of aortic dissection. Chest. 2000; 117(5):1271–1278. [PMID: 10807810]
[7] Moore A G, Eagel K A, and Bruckman D et al.: Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International registry of acute aortic dissection. Am J Cardiol. 2002; 89:1235–1238. [PMID:12008187]



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