Aortic Dissection and Abdominal Aortic Aneurysm Diagnosis and Management

Clinical Presentation and Risk Factors

Aortic dissection presents with sudden-onset severe pain (84-90% of cases) that is maximal at onset, described as sharp, stabbing, tearing, or ripping in quality, with pain location predicting the dissection type, according to the European Heart Journal 1.
Type A dissection (ascending aorta) typically presents with anterior chest pain in 71% of cases, while Type B dissection (descending aorta) presents with back pain in 64% of cases, typically interscapular, as reported by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 2.
Hypertension is a major risk factor for both conditions, present in 65-75% of dissection cases, as stated by Circulation 5.
Dissection-specific risk factors include genetic connective tissue disorders, bicuspid aortic valve, and family history of thoracic aortic disease, according to Circulation 5, 6.

For suspected dissection, immediately transfer to intensive care unit with invasive arterial blood pressure monitoring and administer morphine for pain control, as recommended by the European Heart Journal 1, 8.
Measure blood pressure in both arms—a systolic differential suggests dissection, and check for pulse deficits, new diastolic murmur of aortic regurgitation, and focal neurologic deficits, as suggested by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 2, 3.
For suspected dissection in stable patients, CT angiography of chest, abdomen, and pelvis is the diagnostic test of choice (100% sensitivity), according to Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3.
For suspected AAA, ultrasound is the initial screening test of choice, with multidetector CT or CT angiography optimal for detailed characterization, as recommended by the Journal of the American College of Radiology 4.

Immediately initiate blood pressure and heart rate control targeting systolic BP 100-120 mmHg and heart rate ≤60 bpm for acute dissection, using intravenous beta-blockers as first-line treatment, as recommended by the European Heart Journal 1, 8, 9.
Type A dissection requires emergency surgical repair, while Type B dissection requires medical management with aggressive BP/HR control, unless complicated, in which case TEVAR or surgical intervention is necessary, according to Circulation 6 and the European Heart Journal 10.
Asymptomatic AAA <5.5 cm requires medical management focusing on cardiovascular risk reduction, including smoking cessation, statin therapy, blood pressure control, and LDL-C reduction, as recommended by the European Heart Journal 7.

AAA screening with duplex ultrasound is recommended for men ≥65 years with smoking history, and may be considered for men ≥75 years or women ≥75 years who are current smokers or hypertensive, according to the European Heart Journal 7.
Thoracic aortic disease screening is recommended for first-degree relatives of patients with thoracic aortic aneurysm or dissection, and for patients with Marfan syndrome, Loeys-Dietz syndrome, bicuspid aortic valve, or Turner syndrome, as stated by Circulation 5, 6 and the European Heart Journal 10.