Aortic Dissection Clinical Presentation and Management

Clinical Presentation

The European Society of Cardiology notes that pain is the most common presenting symptom of aortic dissection, with abrupt onset and maximum intensity at the beginning, unlike myocardial infarction pain which typically builds gradually 1, 2
The location of pain varies by dissection type, with retrosternal pain in proximal (Type A) dissections and interscapular/back pain in distal (Type B) dissections 3, 4
The typical patient with aortic dissection is a male in his 60s with a history of hypertension 1, 3
Hypertension is more commonly associated with distal aortic dissection 3, 4
Up to 20% of patients may present with syncope without typical pain or neurological findings 1, 4
Cardiac failure may become the predominant symptom, usually related to severe aortic regurgitation 4, 5
Pulse deficits or limb ischemia may result from obliteration of peripheral vessels 1, 4
Cardiac tamponade may cause hypotension and syncope 4, 5
Oliguria or anuria may occur with renal artery involvement 4, 5

The American College of Emergency Physicians recommends that every patient with suspected aortic dissection should undergo urgent definitive imaging 7, 6
Transesophageal echocardiogram (TEE), computed tomographic imaging (CT), or magnetic resonance imaging (MRI) are all appropriate for diagnosis 7, 6
Selection of specific imaging modality should be based on patient variables and institutional capabilities 6

The American Heart Association recommends reducing systolic blood pressure to 100-120 mmHg using IV beta-blockers as first-line therapy 6
Target heart rate of 60 beats per minute or less 6
For severe hypertension despite beta-blockade, add sodium nitroprusside 6
Provide pain relief with morphine sulfate 6
Transfer to intensive care unit for appropriate monitoring 6
Type A dissection (involving ascending aorta): Urgent surgical consultation and evaluation for emergent surgical repair 6
Type B dissection (involving descending aorta): Initially manage medically unless life-threatening complications develop 6
Surgical options for Type A include implantation of a composite graft in the ascending aorta 6
For complicated Type B dissection, emergency intervention (preferably TEVAR - Thoracic Endovascular Aortic Repair) is recommended 6

Patients with genetic connective tissue disorders (Marfan, Loeys Dietz, Ehlers Danlos syndrome) and bicuspid aortic valves are at increased risk of aortic dissection at a younger age, and lifelong beta-adrenergic blockade is recommended for prevention of dissection 6
For pregnant patients, management requires a multidisciplinary team at specialized centers 6

The European Society of Cardiology notes that thrombolytic therapy can be catastrophic if administered to a patient with aortic dissection misdiagnosed as myocardial infarction 8
Elevated D-dimer may be a helpful laboratory marker but should not be used to rule out dissection 7