Nontraumatic thoracic aortic dissection - Revision history

Danbot: Add MedicationDose entries (esmolol, labetalol, diltiazem, nicardipine, clevidipine, nitroprusside) with SMW annotations

2026-03-20T18:25:08Z

Add MedicationDose entries (esmolol, labetalol, diltiazem, nicardipine, clevidipine, nitroprusside) with SMW annotations

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 *Type B (isolated to descending aorta)
 **Primarily medical management with surgery consultation
 ==Disposition==

Rossdonaldson1: /* Evaluation */

2025-09-17T19:44:07Z

Evaluation

← Older revision		Revision as of 19:44, 17 September 2025
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	==Evaluation==		==Evaluation==
	[[File:1920px-Dissektion im Aortenbogen im Roentgenbild 76W - CR und CT - 001 - Annotation.jpg\|thumb\|Dissection of the aortic arch in X-ray image 76W - CR and CT - 001 - Annotation.jpg\|Dissection of the aortic arch: initial CXR normal visualization of the calcification shadow in the aortic arch (left); CXR 4 months later with calcification shifted centrally into the shadow of the aortic arch with a blurred external border (middle); CT scan coronal (top right) and axial (lower right).]]		[[File:1920px-Dissektion im Aortenbogen im Roentgenbild 76W - CR und CT - 001 - Annotation.jpg\|thumb\|Dissection of the aortic arch in X-ray image 76W - CR and CT - 001 - Annotation.jpg\|Dissection of the aortic arch: initial CXR normal visualization of the calcification shadow in the aortic arch (left); CXR 4 months later with calcification shifted centrally into the shadow of the aortic arch with a blurred external border (middle); CT scan coronal (top right) and axial (lower right).]]
			[[File:Dissection CXR.jpg\|thumbnail\|CXR showing widened mediastinum and porminent aortic knob]]
			[[File:Dissection2018WithPericardial.jpg\|thumb\|Type A dissection with pericardial effusion as a result. Red arrows showing ascending and descending thoracic aorta. The blue arrows pericardial effusion.]]
			[[File:Dissection.png\|thumbnail\|CT chest with contrast of thoracic aortic dissection.]]
	===[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs Aortic Dissection Detection Risk Score (ADD-RS)]===		===[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs Aortic Dissection Detection Risk Score (ADD-RS)]===
	''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features''		''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features''
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	**Left sided pleural effusion (seen in 19%)		**Left sided pleural effusion (seen in 19%)
	**Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign		**Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign
	~~[[File:Dissection CXR.jpg\|thumbnail\|CXR showing widened mediastinum and porminent aortic knob]]~~
	[[File:Dissection2018WithPericardial.jpg\|thumb\|Type A dissection with pericardial effusion as a result. Red arrows showing ascending and descending thoracic aorta. The blue arrows pericardial effusion.]]

	===Low-Intermediate===		===Low-Intermediate===
	''(Based on ADD-RS)''<ref>Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</ref><ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref><ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>		''(Based on ADD-RS)''<ref>Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</ref><ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref><ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>

	*[[D-dimer]] for ADD-RS ≤ 1 (low or intermediate risk)		*[[D-dimer]] for ADD-RS ≤ 1 (low or intermediate risk)

	===High Risk/Definitive===		===High Risk/Definitive===
	~~[[File:Dissection.png\|thumbnail\|CT chest with contrast of thoracic aortic dissection.]]~~
	*CT aortogram chest		*CT aortogram chest
	**Study of choice		**Study of choice

Rossdonaldson1: /* No Risk Factor Screening */

2025-09-17T19:09:20Z

No Risk Factor Screening

← Older revision		Revision as of 19:09, 17 September 2025
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	**Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign		**Widening of aortic contour (seen in 48%), displaced calcification (6mm), Calcium sign (look for white line of calcium within aortic knob and measure to outer edge of the aortic knob - distance greater than 0.5 cm is positive and > 1 cm is highly suspicious for dissection), aortic kinking, double density sign
	[[File:Dissection CXR.jpg\|thumbnail\|CXR showing widened mediastinum and porminent aortic knob]]		[[File:Dissection CXR.jpg\|thumbnail\|CXR showing widened mediastinum and porminent aortic knob]]
			[[File:Dissection2018WithPericardial.jpg\|thumb\|Type A dissection with pericardial effusion as a result. Red arrows showing ascending and descending thoracic aorta. The blue arrows pericardial effusion.]]

	===Low-Intermediate===		===Low-Intermediate===

Rossdonaldson1: /* Evaluation */

2025-09-17T19:03:04Z

Evaluation

← Older revision		Revision as of 19:03, 17 September 2025
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	==Evaluation==		==Evaluation==
			[[File:1920px-Dissektion im Aortenbogen im Roentgenbild 76W - CR und CT - 001 - Annotation.jpg\|thumb\|Dissection of the aortic arch in X-ray image 76W - CR and CT - 001 - Annotation.jpg\|Dissection of the aortic arch: initial CXR normal visualization of the calcification shadow in the aortic arch (left); CXR 4 months later with calcification shifted centrally into the shadow of the aortic arch with a blurred external border (middle); CT scan coronal (top right) and axial (lower right).]]
	===[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs Aortic Dissection Detection Risk Score (ADD-RS)]===		===[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs Aortic Dissection Detection Risk Score (ADD-RS)]===
	''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features''		''A score 1 should be awarded for each of the 3 categories that contain at least one of the listed features''

Rossdonaldson1 at 17:59, 10 September 2025

2025-09-10T17:59:26Z

← Older revision		Revision as of 17:59, 10 September 2025
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	[[File:Aorta segments.jpg\|thumb\|Aortic segments]]		[[File:Aorta segments.jpg\|thumb\|Aortic segments]]
	[[File:Aorta branches.jpg\|thumb\|Branches of the aorta]]		[[File:Aorta branches.jpg\|thumb\|Branches of the aorta]]
			[[File:IJRRT-09-00343-g002.png\|thumb\|Aortic anatomy. The aorta is divided into 5 anatomical segments– aortic root, ascending aorta, aortic arch, descending thoracic aorta, and abdominal aorta. Its wall is composed of three layers – intima, media, and adventitia.]]
	*Most commonly seen in men 60-80 yrs old		*Most commonly seen in men 60-80 yrs old
	*Intimal tear with blood leaking into media		*Intimal tear with blood leaking into media

Rossdonaldson1: /* Aortic Dissection Classification */

2025-09-10T16:52:22Z

Aortic Dissection Classification

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 **Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea
-===[[Aortic Dissection]] Classification===
+{{Aortic dissection classification}}
 ==Management==

Rossdonaldson1: /* Aortic Dissection Classification */

2025-09-10T16:51:37Z

Aortic Dissection Classification

← Older revision		Revision as of 16:51, 10 September 2025
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	===[[Aortic Dissection]] Classification===		===[[Aortic Dissection]] Classification===
	*Stanford		*'''Stanford'''
	**~~'''~~Type A~~'''~~: Involves any portion of ascending aorta		**Type A: Involves any portion of ascending aorta
	**~~'''~~Type B~~'''~~: Isolated to descending aorta		**Type B: Isolated to descending aorta
	*De Bakey		*'''De Bakey'''
	**Type I: Involves the ascending and descending aorta		**Type I: Involves the ascending and descending aorta
	**Type II: Involves only the ascending aorta		**Type II: Involves only the ascending aorta

Rossdonaldson1: /* Classification (Stanford) */

2025-09-10T16:50:26Z

Classification (Stanford)

← Older revision		Revision as of 16:50, 10 September 2025
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	**Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea		**Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea

	===Classification ~~(Stanford)~~===		===[[Aortic Dissection]] Classification===
	*~~Type A~~		*Stanford
	**Involves any portion of ascending aorta		**'''Type A''': Involves any portion of ascending aorta
	*Type B		**'''Type B''': Isolated to descending aorta
	**~~Isolated to~~ descending aorta		*De Bakey
			**Type I: Involves the ascending and descending aorta
			**Type II: Involves only the ascending aorta
			**Type III: Involves only the descending aorta

	{\| class="wikitable"		{\| class="wikitable"

Benalexander: Additional references, edits for clarity, correct minor typos and formatting.

2025-08-01T14:32:29Z

Additional references, edits for clarity, correct minor typos and formatting.

← Older revision		Revision as of 14:32, 1 August 2025
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	''Not to be confused with [[traumatic aortic transection]]''		''Not to be confused with [[traumatic aortic transection]]''
	==Background==		==Background==
	[[File:Aorta segments.jpg\|thumb\|Aortic ~~sebments.~~]]		[[File:Aorta segments.jpg\|thumb\|Aortic segments]]
	[[File:Aorta branches.jpg\|thumb\|Branches of the aorta.]]		[[File:Aorta branches.jpg\|thumb\|Branches of the aorta]]
	*Most commonly seen in men 60-80 yrs old		*Most commonly seen in men 60-80 yrs old
	*Intimal tear with blood leaking into media		*Intimal tear with blood leaking into media
	*Mortality ~~increases~~ 1% per hour of ~~symptoms~~ when ~~untreated~~		*Mortality in first 48 hours of acute presentation is high
			**Commonly quoted as 1-2% per hour, but this is based on a series from the 1950s<ref>Hirst AE Jr, et al. Dissecting aneurysm of the aorta: a review of 505 cases. ''Medicine (Baltimore)''. 1958;37(3):217-279.</ref>
			**More recent data suggests mortality for type A dissection is 0.5% per hour when treated medically, and 0.1% per hour when managed surgically<ref>Harris, KM. et al. Early mortality in type A acute aortic dissection: Insights from the International Registry of Acute Aortic Dissection. ''JAMA Cardiol''. 2022;7(10):1009-1015.</ref>
	*Diagnosis delayed > 24hr in 50% of cases		*Diagnosis delayed > 24hr in 50% of cases
	*Bimodal age distribution		*Bimodal age distribution
	**Young with risk factors		**Young with risk factors
	***[[Connective tissue disease]] (e.g. [[Marfan syndrome]], ~~Ehler's~~-Danlos, collagen vascular disease)		***[[Connective tissue disease]] (e.g. [[Marfan syndrome]], Ehlers-Danlos, collagen vascular disease)
	***[[Pregnancy]], especially 3rd trimester		***[[Pregnancy]], especially 3rd trimester
	***Recent cardiac catheterization		***Recent cardiac catheterization
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	**Study of choice		**Study of choice
	**Similar sensitivity/specificity to TEE and MRA		**Similar sensitivity/specificity to TEE and MRA
			*TEE
			**If CT delayed due to contrast allergy or availability, or patient instability.
			**TEE has a sensitivity of 98% and 95% specific<ref>Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.</ref>

	===Other Findings===		===Other Findings===
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	**Can help in ruling in patients when AOFT is >4cm		**Can help in ruling in patients when AOFT is >4cm
	**Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea		**Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea
	**TEE has a sensitivity of 98% and 95% specific<ref>Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med. 2006 Jul 10;166(13):1350-6.</ref>

	===Classification (Stanford)===		===Classification (Stanford)===
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	==Management==		==Management==
	~~''Lower wall tension by lowering BP (La Place T = P × r)''~~

	*~~Important considerations~~		===General Principles===
	**Right radial arterial line or right arm blood pressure will be the most accurate		*Control pain to reduce sympathetic stimulation.
	**[[Beta blockers]] are good first-line ~~options~~, since they reduce heart rate and aortic wall tension		**[[Fentanyl]] is easily titratable with minimal cardiovascular effects
	***~~However, avoid~~ β-blockers in [[aortic regurgitation]] ~~murmurs or~~ on ~~bedside echo~~		*Right radial arterial line or right arm blood pressure will generally be the most accurate
	**It is important to provide adequate analgesia in order to decrease sympathetic output leading to tachycardia ~~and hypertension~~		*Reducing heart rate while maintaining low-normal blood pressure reduces aortic flow acceleration, thereby reducing shear force on the intimal wall
	~~#Heart rate control ([[beta-blockers]] are first line)~~		**'''Goal: HR < 60 bpm, SBP 100-120 mmHg'''
			**Control heart rate before blood pressure<ref>[https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.105.534198 Tsai TT, Nienaber CA, and Eagle KA. Acute Aortic Syndromes. Circulation. 2005;112:3802–3813]</ref>
			**[[Beta blockers]] are good first-line option, since they reduce heart rate and aortic wall tension
			***Use β-blockers with caution in severe, acute [[aortic regurgitation]] - may worsen shock if dependent on compensatory tachycardia

	===Heart Rate control===		===Heart Rate control===
	;Control heart rate before blood pressure (Goal to keep HR <60 bpm and SBP 100-120)<ref>[https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.105.534198 Tsai TT, Nienaber CA, and Eagle KA. Acute Aortic Syndromes. Circulation. 2005;112:3802–3813]</ref>
	#[[Esmolol]]		#[[Esmolol]]
	#*Advantage of short half life, easily titratable		#*Advantage of short half life, easily titratable
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	===Blood pressure control (vasodilators)===		===Blood pressure control (vasodilators)===
	~~#*Do not control blood pressure without adequate heart rate control (must suppress reflex tachycardia which will shear forces from increased HR)~~		Use if needed after beta-blockade.
	#[[Nicardipine]]~~/[[Clevidipine]] - consider following regimen for nicardipine~~:		#[[Nicardipine]]:
	#*5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal		#*5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal
	#*Once at goal, drop to 3mg/hr and re-titrate from there		#*Once at goal, drop to 3mg/hr and re-titrate from there
	#*May initially bolus 2mg IV<ref>Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf</ref>		#*May initially bolus 2mg IV<ref>Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf</ref>
			#[[Clevidipine]]
			#*1-2 mg/hr
			#*Double dose every 90 seconds until approaching goal BP, then increase in smaller amounts every 5-10 minutes until goal achieved.<ref>UpToDate Inc. Clevidipine [Drug information]. In:UpToDate Lexidrug. Wolters Kluwer; 2025. Accessed August 1, 2025.</ref>
	#[[Nitroprusside]] 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity		#[[Nitroprusside]] 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity
	#[[Fenoldopam]]		#[[Fenoldopam]]
	#[[Enalapril]]		#[[Enalapril]]
	~~#[[Analgesia]]~~
	~~#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output~~

	===Surgery===		===Surgery===

Azhandos: /* Low-Intermediate (Based on ADD-RS)Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.Shimony A, et al. Meta-analysis...

2024-10-30T17:53:59Z

/* Low-Intermediate (Based on ADD-RS)Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.Shimony A, et al. Meta-analysis...

← Older revision		Revision as of 17:53, 30 October 2024
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	[[File:Dissection CXR.jpg\|thumbnail\|CXR showing widened mediastinum and porminent aortic knob]]		[[File:Dissection CXR.jpg\|thumbnail\|CXR showing widened mediastinum and porminent aortic knob]]

	===Low-Intermediate (Based on ADD-RS)<ref>Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</ref><ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref><ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>~~===~~		===Low-Intermediate===
			''(Based on ADD-RS)''<ref>Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</ref><ref>Asha SE et al. "A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection." Annals of EM. 66;4;368-377Ocotber 2015.</ref><ref>Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.</ref>

	*[[D-dimer]] for ADD-RS ≤ 1 (low or intermediate risk)		*[[D-dimer]] for ADD-RS ≤ 1 (low or intermediate risk)