Diagnosis and management of acute aortic syndromes in the emergency department
- 1 January 2021
- journal article
- review article
- Published by Springer Science and Business Media LLC in Internal and Emergency Medicine
- Vol. 16 (1), 171-181
- https://doi.org/10.1007/s11739-020-02354-8
Abstract
Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and d-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.Keywords
This publication has 62 references indexed in Scilit:
- Correlates of Delayed Recognition and Treatment of Acute Type A Aortic DissectionCirculation, 2011
- Sensitivity of the Aortic Dissection Detection Risk Score, a Novel Guideline-Based Tool for Identification of Acute Aortic Dissection at Initial PresentationCirculation, 2011
- Focused Cardiac Ultrasound in the Emergent Setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency PhysiciansJournal of the American Society of Echocardiography, 2010
- 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic DiseaseCirculation, 2010
- Risk Factors for Diagnostic Delay in Acute Aortic DissectionThe American Journal of Cardiology, 2008
- Frequency of and Inappropriate Treatment of Misdiagnosis of Acute Aortic DissectionThe American Journal of Cardiology, 2007
- Neurological Symptoms in Type A Aortic DissectionsStroke, 2007
- Comparative Safety of Atorvastatin 80 mg Versus 10 mg Derived from Analysis of 49 Completed Trials in 14,236 PatientsThe American Journal of Cardiology, 2006
- Acute Aortic Dissection Presenting With Congestive Heart Failure: Results From the International Registry of Acute Aortic DissectionJournal of the American College of Cardiology, 2005
- Clinical characteristics of hypotension in patients with acute aortic dissectionThe American Journal of Cardiology, 2005