Difference between revisions of "Nontraumatic thoracic aortic dissection"

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**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]], Ehler's-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)
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{| class="wikitable"
 
{| class="wikitable"
 
|+Classification of aortic dissection
 
|+Classification of aortic dissection
|-
+
|- style="background:white;"
|valign="top"|
+
|valign="top"|'''Image'''
 
|[[File:AoDissect DeBakey1.png|90px]]
 
|[[File:AoDissect DeBakey1.png|90px]]
 
|[[File:AoDissect DeBakey2.png|90px]]
 
|[[File:AoDissect DeBakey2.png|90px]]
 
|[[File:AoDissect DeBakey3.png|90px]]
 
|[[File:AoDissect DeBakey3.png|90px]]
|- style="background:#dcdcdc;"
+
|- style="background:white;"
||Percentage
+
||'''Percentage'''
 
|  style="text-align:center; "|60%
 
|  style="text-align:center; "|60%
 
|  style="text-align:center; "|10–15%
 
|  style="text-align:center; "|10–15%
 
|  style="text-align:center; "|25–30%
 
|  style="text-align:center; "|25–30%
|-
+
|- style="background:white;"
|style="border-bottom:white"|Type
+
||'''Type'''
 
| style="text-align:center;" border="0"|DeBakey I
 
| style="text-align:center;" border="0"|DeBakey I
 
| style="text-align:center;"|DeBakey II
 
| style="text-align:center;"|DeBakey II
 
| style="text-align:center;"|DeBakey III
 
| style="text-align:center;"|DeBakey III
|-
+
|- style="background:white;"
|style="border-bottom:white"|
+
||'''Classification'''
 
| colspan=2 style="text-align:center;"|Stanford A (Proximal)
 
| colspan=2 style="text-align:center;"|Stanford A (Proximal)
 
| style="text-align:center;"|Stanford B (Distal)
 
| style="text-align:center;"|Stanford B (Distal)
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===General===
 
===General===
 
*Symptoms
 
*Symptoms
**Tearing/ripping pain (10.8x increased disease probability)
+
**Tearing/ripping [[chest pain|pain]] (10.8x increased disease probability)
 
**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
 
*Studies
 
**Enlarged aorta or widened mediastinum (3.4x)
 
**Enlarged aorta or widened mediastinum (3.4x)
**LVH on admission ECG (3.2x)
+
**[[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]]
 +
 +
==Complications==
 +
*AV Regurgitation/Insufficiency
 +
**[[CHF]] with diastolic murmur
 +
*Rupture
 +
**Pericardium: [[cardiac tamponade]]
 +
**Mediastinum: [[hemothorax]]
 +
*Vascular obstruction
 +
**Coronary: [[ACS]]
 +
**Carotid: [[CVA]]
 +
**Lumbar: Paraplegia
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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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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[[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 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 (Based on AAD) Risk Rule-Out<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]]
+
*[[D-dimer]] for ADD score ≤ 1 (low or intermediate risk)
**May use for ADD score = 0 (post test probability <0.3%)
 
**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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**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>
 
**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>
  
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*Important considerations
 
*Important considerations
 
**Right radial arterial line or right arm blood pressure will be the most accurate
 
**Right radial arterial line or right arm blood pressure will be the most accurate
**Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension
+
**[[Beta blockers]] are good first-line options, since they reduce heart rate and aortic wall tension
**However, avoid β-blockers in [[aortic regurgitation]] murmurs or on bedside echo
+
***However, avoid β-blockers in [[aortic regurgitation]] murmurs or on bedside echo
**Do not start [[nitroprusside]] until tachycardia resolves to avoid reflexive tachycardia
 
 
#Heart rate control ([[beta-blockers]] are first line)
 
#Heart rate control ([[beta-blockers]] are first line)
 
#*[[Esmolol]]  
 
#*[[Esmolol]]  
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#*[[Diltiazem]] - Use if contraindications to beta-blockers
 
#*[[Diltiazem]] - Use if contraindications to beta-blockers
 
#**Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
 
#**Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
#Blood pressure control (vasodialators)
+
#Blood pressure control (vasodilators)
 
#*Only use if beta-blocker is ineffective  
 
#*Only use if beta-blocker is ineffective  
 
#*Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)  
 
#*Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)  
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#**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>
 
#*[[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
+
#[[Analgesia]]
 
#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output
 
#*[[Morphine]]/[[Fentanyl]] - Decreases sympathetic output
  
 
==Disposition==
 
==Disposition==
 
*Admission to OR or ICU
 
*Admission to OR or ICU
 
==Complications==
 
*AV Regurgitation/Insufficiency
 
**[[CHF]] with diastolic murmur
 
*Rupture
 
**Pericardium: tamponade
 
**Mediastinum: hemothorax
 
*Vascular obstruction
 
**Coronary: ACS
 
**Carotid: CVA
 
**Lumbar: Paraplegia
 
  
 
==See Also==
 
==See Also==
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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 16:01, 25 September 2019

Not to be confused with traumatic aortic transection

Background

  • Most commonly seen in men 60-80 yrs old
  • Intimal tear with blood leaking into media
  • Mortality increases 1% per hour of symptoms when untreated
  • Diagnosis delayed > 24hr in 50% of cases
  • Bimodal age distribution

Classification (Stanford)

  • Type A - Involves any portion of ascending aorta
    • Requires surgery
  • Type B - Isolated to descending aorta
    • Primarily medical management with surgery consultation
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)

Clinical Features

General

  • Symptoms
    • Tearing/ripping pain (10.8x increased disease probability)
    • Migrating pain (7.6x)
    • Sudden chest pain (2.6x)
    • History of hypertension (1.5x)
  • Signs
  • Studies
    • Enlarged aorta or widened mediastinum (3.4x)
    • LVH on admission ECG (3.2x)

Specific

Complications

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

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Hypertension

Evaluation

Acute Aortic Dissection (AAD) Risk Score

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%
    • 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
CXR showing widened mediastinum and porminent aortic knob

Low-Intermediate (Based on AAD) Risk Rule-Out[3][4][5]

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

High Risk/Definitive

  • CT aortogram chest
    • Study of choice
    • Similar sensitivity/specificity to TEE and MRA
CT chest with contrast of thoracic aortic dissection.

Other Findings

  • ECG
    • 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
    • TEE has a sensitivity of 98% and 95% specific[6]
Type A Aortic Dissection[7]

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)
  • Important considerations
    • Right radial arterial line or right arm blood pressure will be the most accurate
    • Beta blockers are good first-line options, since they reduce heart rate and aortic wall tension
  1. Heart rate control (beta-blockers are first line)
    • Esmolol
      • Advantage of short half life, easily titratable
      • Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
      • Esmolol Drip Sheet
    • 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
    • Metoprolol
      • 5mg IV x 3; infuse at 2-5mg/hr
    • Diltiazem - Use if contraindications to beta-blockers
      • Loading 0.25mg/kg over 2–5 min, followed by a drip of 5mg/h
  2. Blood pressure control (vasodilators)
    • Only use if beta-blocker is ineffective
    • Do not use without a beta-blocker (must suppress reflex tachycardia - shear forces from increased HR)
    • Nicardipine/Clevidipine - consider following regimen for 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[8]
    • Nitroprusside 0.3-0.5mcg/kg/min - Risk of cerebral blood vessel vasodilation and CN/Thiocynate toxicity
    • Fenoldopam
    • Enalapril
  3. Analgesia

Disposition

  • Admission to OR or ICU

See Also

External Links

References

  1. 1.0 1.1 1.2 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.
  2. 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.
  3. 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.
  4. 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.
  5. Shimony A, et al. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am J Cardiol. 2011; 107(8):1227-1234.
  6. 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.
  7. http://www.thepocusatlas.com/echocardiography-1
  8. Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf