Management of Acute Aortic Syndrome

Initial Assessment and Diagnosis

The European Society of Cardiology recommends ECG-gated CT angiography from neck to pelvis as the first-line imaging technique for suspected acute aortic syndrome, providing crucial information about entry tears, extension, and complications 4
Focused transthoracic echocardiography (with contrast if feasible) is recommended during initial evaluation to assess for complications, according to the European Heart Journal 4
Transesophageal echocardiography is recommended in unstable patients who cannot be transferred for CT and to guide perioperative management, as stated in the European Heart Journal 4
A multiparametric algorithm using the aortic dissection detection-risk score (ADD-RS) with D-dimer is recommended for ruling in or out acute aortic syndrome, as per the European Heart Journal 4

The European Heart Journal recommends intravenous beta-blockers (preferably labetalol due to its alpha- and beta-blocking properties) as the first-line agents for initial anti-impulse therapy 1, 2
If beta-blockers are contraindicated, non-dihydropyridine calcium channel blockers should be considered, according to the European Heart Journal 2
Intravenous vasodilators (e.g., dihydropyridine calcium blockers or nitrates) can be added if necessary to achieve target blood pressure, as recommended by the European Heart Journal 1, 2
Adequate pain control with intravenous opiates is essential to achieve hemodynamic targets, as stated in the European Heart Journal 1

For Type A aortic dissection, emergency surgical consultation and immediate surgical intervention is recommended, according to the European Heart Journal 1, 4
For complicated acute Type B dissection, emergency intervention with thoracic endovascular aortic repair (TEVAR) is recommended as first-line therapy, as per the European Heart Journal 1
For uncomplicated acute Type B dissection, TEVAR in the subacute phase (14-90 days) should be considered in selected patients with high-risk features, according to the European Heart Journal 5
For chronic Type B dissection with descending thoracic aortic diameter ≥60 mm, intervention is recommended in patients at reasonable surgical risk, as stated in the European Heart Journal 1, 7

For medically treated Type B acute aortic syndrome or intramural hematoma, imaging at 1, 3, 6, and 12 months after onset, then yearly if stable, is recommended by the European Heart Journal 7
After open surgery for acute aortic syndrome, imaging by CT and TTE within 6 months, then CT at 12 months and yearly if stable, is recommended, according to the European Heart Journal 7
After TEVAR, follow-up imaging at 1 and 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalities are documented, is recommended by the European Heart Journal 4