Nontraumatic thoracic aortic dissection: Difference between revisions

(I fixed the reference error for my contribution on October 4th)
(Add MedicationDose entries (esmolol, labetalol, diltiazem, nicardipine, clevidipine, nitroprusside) with SMW annotations)
 
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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 segments]]
[[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
*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
***[[Chest trauma]]
***Recent cardiac catheterization
***Recent cardiac catheterization
***Bicuspid aortic valve
***Bicuspid aortic valve
***Aortic coarctation
***[[coarctation of the Aorta|Aortic coarctation]]
**Elderly males with chronic hypertension
**Elderly males with chronic hypertension
**Atherosclerotic risk factors (smoking, hypertension, HLD, DM)
**Atherosclerotic risk factors (smoking, hypertension, HLD, DM)
===Classification (Stanford)===
*Type A - Involves any portion of ascending aorta
**Requires surgery
*Type B - Isolated to descending aorta
**Primarily medical management with surgery consultation
{| class="wikitable"
|+Classification of aortic dissection
|-
|valign="top"|
|[[File:AoDissect DeBakey1.png|90px]]
|[[File:AoDissect DeBakey2.png|90px]]
|[[File:AoDissect DeBakey3.png|90px]]
|- style="background:#dcdcdc;"
||Percentage
|  style="text-align:center; "|60%
|  style="text-align:center; "|10–15%
|  style="text-align:center; "|25–30%
|-
|style="border-bottom:white"|Type
| style="text-align:center;" border="0"|DeBakey I
| style="text-align:center;"|DeBakey II
| style="text-align:center;"|DeBakey III
|-
|style="border-bottom:white"|
| colspan=2 style="text-align:center;"|Stanford A (Proximal)
| style="text-align:center;"|Stanford B (Distal)
|-
|}


==Clinical Features==
==Clinical Features==
===General===
===General===
*Symptoms
*Symptoms
**Tearing/ripping pain (10.8x increased disease probability)
**Tearing/ripping [[chest pain|pain]] (10.8x increased disease probability)
***64% described the pain as sharp vs 50.6% who described it as tearing or ripping<ref>Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.</ref>
**Migrating pain (7.6x)
**Migrating pain (7.6x)
**Sudden chest pain (2.6x)
**Sudden chest pain (2.6x)
**History of hypertension (1.5x)
**History of [[hypertension]] (1.5x)
*Signs
*Signs
**Focal neurologic deficit (33x)
**[[Focal neuro deficit|Focal neurologic deficit]] (33x)
**Diastolic heart murmur (acute aortic regurg) (4.9x)
**Diastolic heart [[murmur]] (acute aortic regurg) (4.9x)
**Pulse deficit (2.7x)
**Pulse deficit (2.7x)
**Hypertension at time of presentation (49% of all cases<ref name="a">Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.</ref>)
**[[Hypertension]] at time of presentation (49% of all cases<ref name="a">Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.</ref>)
*Studies
**Enlarged aorta or widened mediastinum (3.4x)
**LVH on admission ECG (3.2x)


===Specific===
===Specific===
*Ascending Aorta
*Ascending Aorta
**Acute [[aortic regurgitation]], leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66%  
**Acute [[aortic regurgitation]], leading to a diastolic decrescendo [[murmur]], [[hypotension]], or [[heart failure]], in 50%-66%  
**[[MI]]/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery<ref>Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.</ref>)
**[[MI]]/Ischemia on ECG, usually inferior (dissection affects the right coronary artery more often than the left coronary artery<ref>Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.</ref>)
**[[Cardiac Tamponade]]
**[[Cardiac Tamponade]]
**[[Hemothorax]] - if adventitia disruption
**[[Hemothorax]] - if adventitia disruption
**Horners, partial - sympathetic ganglion
**[[Horner syndrome|Horners]], partial - sympathetic ganglion
**Voice hoarseness - recurrent laryngeal n. compression
**Voice hoarseness - recurrent laryngeal nerve compression
**CVA/[[Syncope]] - if carotid extension
**[[CVA]]/[[Syncope]] - if carotid extension
**Neurological deficits
**[[Focal neuro deficit|Neurological deficits]]
**SBP>20mmhg difference between arms
**SBP>20mmhg difference between arms
**Hypertension at time of presentation (35.7% of all cases<ref name="a"/>)
**[[Hypertension]] at time of presentation (35.7% of all cases<ref name="a"/>)
*Descending Aorta
*Descending Aorta
**[[Chest pain]], back pain, abdominal pain
**[[Chest pain]], [[back pain]], [[abdominal pain]]
***Chest Pain - Abrupt, severe (90% of patients) radiating to back  
***Pain abrupt, severe (90% of patients) radiating to back  
**Hypertension at time of presentation (70.1% of all cases<ref name="a" />)
**[[Hypertension]] at time of presentation (70.1% of all cases<ref name="a" />)
**Hemiplegia, neuropathy (15%)
**[[Weakness|Hemiplegia]], neuropathy (15%)
**Renal failure
**[[Renal failure]]
**Distal Pulse deficits/ [[limb ischemia]]
**Distal Pulse deficits/ [[limb ischemia]]
**[[Mesenteric ischemia]]
**[[Mesenteric ischemia]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Chest Pain DDX}}
{{Chest Pain DDX}}
 
{{Hypertension DDX}}
{{Hypertension DDX}}


==Evaluation==
==Evaluation==
===Acute Aortic Dissection (AAD) Risk Score===
[[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)]===
''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''
{| class="wikitable"
{| class="wikitable"
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|-
|-
|  
|  
*Marfan syndrome
*[[Marfan syndrome]]
*Connective tissue disease
*[[Connective tissue disease]]
*Family history of aortic disease
*Family history of aortic disease
*Recent aortic manipulation
*Recent aortic manipulation
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**Pulse deficit
**Pulse deficit
**Systolic BP differential
**Systolic BP differential
**Focal neuological deficit (in conjunction with pain)
**Focal neurological deficit (in conjunction with pain)
*Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
*Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
*[[Hypotension]]of shock state
*[[Hypotension]] of shock state
|}
|}


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===No Risk Factor Screening===
===No Risk Factor Screening===
*[[CXR]]
*[[CXR]]
**Abnormal in 90%  
**Abnormal in 90% (3.4x)
**Mediastinal widening (seen in 56-63%)  
**Mediastinal widening (seen in 56-63%)  
**Left sided pleural effusion (seen in 19%)  
**Left sided pleural effusion (seen in 19%)  
**Widening of aortic contour (seen in 48%), displaced calcification (6mm), 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]]
 


===Low AAD risk Rule-Out<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>===
===Low-Intermediate===
*[[D-dimer]]
''(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>
**May use for ADD score = 0 (post test probability <0.3%)
*[[D-dimer]] for ADD-RS ≤ 1 (low or intermediate risk)
**Sn 0.97 and Sp 0.56 (NPV 0.96)<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>
**ACEP considers D-dimer as Level C<ref>Diercks DB, et al. Clinical policy: Critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015; 65(1):32-42e12.</ref>


===High Risk/Definitive===
===High Risk/Definitive===
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**Study of choice
**Study of choice
**Similar sensitivity/specificity to TEE and MRA
**Similar sensitivity/specificity to TEE and MRA
[[File:Dissection.png|thumbnail|CT chest with contrast of thoracic aortic dissection.]]
*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===
[[File:aorticdissection.gif|thumbnail|Type A Aortic Dissection<ref>http://www.thepocusatlas.com/echocardiography-1</ref>]]
[[File:USDissection.png|thumbnail|Abdominal Aortic Dissection on Ultrasound]]
*[[ECG]]
*[[ECG]]
**[[LVH]] on admission ECG (3.2x)
**Ischemia (esp inferior) - 15%  
**Ischemia (esp inferior) - 15%  
**Nonspec ST-T changes - 40%  
**Nonspec ST-T changes - 40%  
*Bedside US
*[[echocardiography|Bedside US]]
**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
**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>
 
{{Aortic dissection classification}}


==Management==
==Management==
''Lower wall tension by lowering BP (La Place T = P × r)''
 
;Control heart rate before blood pressure (Goal to keep HR 60-80 and SBP 100-120)
===General Principles===
*Important considerations
*Control pain to reduce sympathetic stimulation.
**Right radial arterial line or right arm blood pressure will be the most accurate
**[[Fentanyl]] is easily titratable with minimal cardiovascular effects
**Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension
*Right radial arterial line or right arm blood pressure will generally be the most accurate
**However, avoid β-blockers in [[aortic regurgitation]] murmurs or on bedside echo
*Reducing heart rate while maintaining low-normal blood pressure reduces aortic flow acceleration, thereby reducing shear force on the intimal wall
**Do not start [[nitroprusside]] until tachycardia resolves to avoid reflexive tachycardia
**'''Goal: HR < 60 bpm, SBP 100-120 mmHg'''
#Heart rate control ([[beta-blockers]] are first line)
**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>
#*[[Esmolol]]  
**[[Beta blockers]] are good first-line option, since they reduce heart rate and aortic wall tension
#**Advantage of short half life, easily titratable  
***Use β-blockers with caution in severe, acute [[aortic regurgitation]] - may worsen shock if dependent on compensatory tachycardia
#**Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
 
#**[http://emcrit.org/wp-content/uploads/2013/01/esmolol-drip-sheet.pdf Esmolol Drip Sheet]  
===Heart Rate control===
#*[[Labetalol]] - has both α and beta effects
#[[Esmolol]]  
#**Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
#*Advantage of short half life, easily titratable  
#**Drip - Load 15-20mg IV, followed by 5mg/hr
#*Bolus 0.5mg/kg over 1min; infuse 0.05mg/kg/min (titrate upward in 0.05mg/kg/min increments to a maximum of 0.3 mg/kg/min)
#*[[Metoprolol]]  
#*[http://emcrit.org/wp-content/uploads/2013/01/esmolol-drip-sheet.pdf Esmolol Drip Sheet]  
#**5mg IV x 3; infuse at 2-5mg/hr
#[[Labetalol]] - has both α and beta effects
#*[[Diltiazem]] - Use if contraindications to beta-blockers
#*Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
#**Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
#*Drip - Load 15-20mg IV, followed by 5mg/hr
#Blood pressure control (vasodialators)
#[[Metoprolol]]  
#*Only use if beta-blocker is ineffective
#*5mg IV x 3; infuse at 2-5mg/hr
#*Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)
#[[Diltiazem]] - Use if contraindications to beta-blockers
#*[[Nicardipine]]/Clevidipine - consider following regimen for nicardipine:
#*Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
#**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
===Blood pressure control (vasodilators)===
#**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>
Use if needed after beta-blockade.
#*[[Nitroprusside]] 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity
#[[Nicardipine]]:
#*Fenoldopam
#*5mg/hr start, then titrate up by 2.5mg/hr every 10 min until goal
#*[[Enalapril]]
#*Once at goal, drop to 3mg/hr and re-titrate from there
#Analgesia
#*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>
#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output
#[[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
#[[Fenoldopam]]
#[[Enalapril]]
 
===Surgery===
*Type A (any portion of ascending aorta)
**Requires surgery
*Type B (isolated to descending aorta)
**Primarily medical management with surgery consultation
 
 
==Medication Dosing==
<div style="display:none">
{{MedicationDose
| drug = Esmolol
| dose = 0.5mg/kg bolus, then 50-200mcg/kg/min infusion
| route = IV
| context = First-line heart rate control; easily titratable
| indication = Nontraumatic thoracic aortic dissection
| population = Adult
| notes = Bolus over 1 minute
}}
{{MedicationDose
| drug = Labetalol
| dose = 20mg bolus, then 40-80mg q10min (max 300mg) or 1-2mg/min drip
| route = IV
| context = Heart rate and blood pressure control
| indication = Nontraumatic thoracic aortic dissection
| population = Adult
}}
{{MedicationDose
| drug = Diltiazem
| dose = 0.25mg/kg load over 2-5min, then 5mg/hr infusion
| route = IV
| context = Heart rate control if beta-blocker contraindicated
| indication = Nontraumatic thoracic aortic dissection
| population = Adult
}}
{{MedicationDose
| drug = Nicardipine
| dose = 5mg/hr, titrate by 2.5mg/hr q10min
| route = IV
| context = Blood pressure control (vasodilator) after beta-blockade
| indication = Nontraumatic thoracic aortic dissection
| population = Adult
| notes = Once at goal, drop to 3mg/hr and re-titrate
}}
{{MedicationDose
| drug = Clevidipine
| dose = 1-2mg/hr, double q90sec until approaching goal
| route = IV
| context = Blood pressure control (vasodilator) after beta-blockade
| indication = Nontraumatic thoracic aortic dissection
| population = Adult
}}
{{MedicationDose
| drug = Nitroprusside
| dose = 0.3-0.5mcg/kg/min
| route = IV
| context = Blood pressure control (vasodilator) after beta-blockade
| indication = Nontraumatic thoracic aortic dissection
| population = Adult
| notes = Risk of cerebral vasodilation and cyanide/thiocyanate toxicity
}}
</div>


==Disposition==
==Disposition==
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**[[CHF]] with diastolic murmur  
**[[CHF]] with diastolic murmur  
*Rupture  
*Rupture  
**Pericardium: tamponade  
**Pericardium: [[cardiac tamponade]]
**Mediastinum: hemothorax  
**Mediastinum: [[hemothorax]]
*Vascular obstruction  
*Vascular obstruction  
**Coronary: ACS  
**Coronary: [[ACS]]
**Carotid: CVA  
**Carotid: [[CVA]]
**Lumbar: Paraplegia
**Lumbar: Paraplegia


==See Also==
==See Also==
 
*[[Hypertensive emergency]]  
*[[Hypertensive Emergency]]  
*[[Traumatic aortic transection]]  
*[[Aortic Transection]]  
*[[Abdominal aortic aneurysm]]
*[[Abdominal Aortic Aneurysm (AAA)]]
*[[IRAD]]
*[[IRAD]]


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*[http://emupdates.com/2010/06/23/accaha-aortic-dissection-guideline/ AHA Quick Summary]
*[http://emupdates.com/2010/06/23/accaha-aortic-dissection-guideline/ AHA Quick Summary]
*[http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/ ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)]
*[http://academiclifeinem.com/paucis-verbis-international-registry-on-aortic-dissection-irad/ ALiEM Paucis Verbis: International Registry on Aortic Dissection (IRAD)]
*[https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs#evidence MDcalc ADD Score]


==References==
==References==

Latest revision as of 18:25, 20 March 2026

Not to be confused with traumatic aortic transection

Background

Aortic segments
Branches of the aorta
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
  • Intimal tear with blood leaking into media
  • 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[1]
    • 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[2]
  • Diagnosis delayed > 24hr in 50% of cases
  • Bimodal age distribution

Clinical Features

General

  • Symptoms
    • Tearing/ripping pain (10.8x increased disease probability)
      • 64% described the pain as sharp vs 50.6% who described it as tearing or ripping[3]
    • Migrating pain (7.6x)
    • Sudden chest pain (2.6x)
    • History of hypertension (1.5x)
  • Signs

Specific

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Hypertension

Evaluation

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).
CXR showing widened mediastinum and porminent aortic knob
Type A dissection with pericardial effusion as a result. Red arrows showing ascending and descending thoracic aorta. The blue arrows pericardial effusion.
CT chest with contrast of thoracic aortic dissection.

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

Predisposing conditions Pain features Physical findings

Chest, back, or abdominal pain described as:

  • Abrupt in onset/severe in intensity

AND

  • Ripping/tearing/sharp or stabbing quality
  • Evidence of perfusion deficit
    • Pulse deficit
    • Systolic BP differential
    • Focal neurological deficit (in conjunction with pain)
  • Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
  • Hypotension of shock state
Score Category Prevalence
0 Low 6%
1 Intermediate 27%
>1 High 39%

No Risk Factor Screening

  • CXR
    • Abnormal in 90% (3.4x)
    • Mediastinal widening (seen in 56-63%)
    • 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


Low-Intermediate

(Based on ADD-RS)[6][7][8]

  • D-dimer for ADD-RS ≤ 1 (low or intermediate risk)

High Risk/Definitive

  • CT aortogram chest
    • Study of choice
    • 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[9]

Other Findings

Type A Aortic Dissection[10]
Abdominal Aortic Dissection on Ultrasound
  • ECG
    • LVH on admission ECG (3.2x)
    • Ischemia (esp inferior) - 15%
    • Nonspec ST-T changes - 40%
  • Bedside US
    • Can help in ruling in patients when AOFT is >4cm
    • Rule out pericardial effusion and tamponade, especially in hypotension, syncope, dyspnea


Aortic Dissection Classification

  • Stanford
    • Type A: Involves any portion of ascending aorta
    • Type B: 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
Classification of aortic dissection
Image AoDissect DeBakey1.png AoDissect DeBakey2.png AoDissect DeBakey3.png
Percentage 60% 10–15% 25–30%
Type DeBakey I DeBakey II DeBakey III
Classification Stanford A (Proximal) Stanford B (Distal)

Management

General Principles

  • Control pain to reduce sympathetic stimulation.
    • Fentanyl is easily titratable with minimal cardiovascular effects
  • Right radial arterial line or right arm blood pressure will generally be the most accurate
  • Reducing heart rate while maintaining low-normal blood pressure reduces aortic flow acceleration, thereby reducing shear force on the intimal wall
    • Goal: HR < 60 bpm, SBP 100-120 mmHg
    • Control heart rate before blood pressure[11]
    • 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

  1. Esmolol
    • Advantage of short half life, easily titratable
    • Bolus 0.5mg/kg over 1min; infuse 0.05mg/kg/min (titrate upward in 0.05mg/kg/min increments to a maximum of 0.3 mg/kg/min)
    • Esmolol Drip Sheet
  2. Labetalol - has both α and beta effects
    • Push dose - 10-20mg with repeat doses of 20-40mg q10min up to 300mg
    • Drip - Load 15-20mg IV, followed by 5mg/hr
  3. Metoprolol
    • 5mg IV x 3; infuse at 2-5mg/hr
  4. Diltiazem - Use if contraindications to beta-blockers
    • Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h

Blood pressure control (vasodilators)

Use if needed after beta-blockade.

  1. Nicardipine:
    • 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
    • May initially bolus 2mg IV[12]
  2. 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.[13]
  3. Nitroprusside 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity
  4. Fenoldopam
  5. Enalapril

Surgery

  • Type A (any portion of ascending aorta)
    • Requires surgery
  • Type B (isolated to descending aorta)
    • Primarily medical management with surgery consultation


Medication Dosing

Esmolol 0.5mg/kg bolus, then 50-200mcg/kg/min infusion IV — Bolus over 1 minute Labetalol 20mg bolus, then 40-80mg q10min (max 300mg) or 1-2mg/min drip IV Diltiazem 0.25mg/kg load over 2-5min, then 5mg/hr infusion IV Nicardipine 5mg/hr, titrate by 2.5mg/hr q10min IV — Once at goal, drop to 3mg/hr and re-titrate Clevidipine 1-2mg/hr, double q90sec until approaching goal IV Nitroprusside 0.3-0.5mcg/kg/min IV — Risk of cerebral vasodilation and cyanide/thiocyanate toxicity

Disposition

  • Admission to OR or ICU

Complications

  • AV Regurgitation/Insufficiency
    • CHF with diastolic murmur
  • Rupture
  • Vascular obstruction
    • Coronary: ACS
    • Carotid: CVA
    • Lumbar: Paraplegia

See Also

External Links

References

  1. ↑ Hirst AE Jr, et al. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore). 1958;37(3):217-279.
  2. ↑ 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.
  3. ↑ Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.
  4. ↑ 4.0 4.1 4.2 Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.
  5. ↑ Spittell PC, S et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990) Mayo Clin Proc. 1993;68:642–51.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.
  9. ↑ 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.
  10. ↑ http://www.thepocusatlas.com/echocardiography-1
  11. ↑ Tsai TT, Nienaber CA, and Eagle KA. Acute Aortic Syndromes. Circulation. 2005;112:3802–3813
  12. ↑ Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf
  13. ↑ UpToDate Inc. Clevidipine [Drug information]. In:UpToDate Lexidrug. Wolters Kluwer; 2025. Accessed August 1, 2025.
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