Acute Aortic Syndrome

Definition and Classification

• The European Society of Cardiology defines Acute Aortic Syndrome (AAS) as a condition characterized by damage to the aortic wall with dynamic and overlapping pathophysiology, similar clinical presentation, and common diagnostic and therapeutic approaches 1
• AAS can also be iatrogenic after open, endovascular, or cardiac surgery procedures 1

Epidemiology and Risk Factors

• The average age of presentation is around 63 years, with a higher incidence in men (65%) 2
• Patients with AAS type A have twice the mortality of those with type B (25% vs 12%) 2
• Hypertension is present in 65-75% of cases, often poorly controlled 2
• Genetic diseases, such as Marfan syndrome, are a significant risk factor 1

Clinical Presentation

• Chest pain is the most frequent symptom 3
• Characteristics of pain: abrupt onset, severe intensity, tearing or ripping sensation 3
• Location: chest (80%), back (40%), and abdomen (25%) 3

Diagnosis

• The Aortic Dissection Detection-Risk Score (ADD-RS) helps to stratify risk 1
• Computed Tomography (CT) scan without delay is the initial test of choice 1, 4
• Focused transthoracic echocardiography + ECG is a rapid initial evaluation 1
• Transesophageal echocardiography is useful in hemodynamically unstable patients 4, 5

Treatment

• Management depends on the type and location of AAS 6
• Type A AAS requires urgent surgery to prevent fatal complications such as rupture, cardiac tamponade, or severe aortic insufficiency 6
• Type B AAS: complicated cases require urgent endovascular repair, while uncomplicated cases may be managed medically with close follow-up 6

Prognosis

• Prognosis depends on the type of AAS, prompt diagnosis, and timely treatment 2
• Mortality remains high, especially in untreated type A AAS 2
• Long-term follow-up is essential to detect late complications 2

Acute Aortic Syndrome

Classification and Characteristics

• The European Society of Cardiology classifies acute aortic syndrome into several types, including classic dissection, intramural hematoma, and penetrating aortic ulcer, with each having distinct characteristics and management approaches 7, 8
• Intramural hematoma (Class 2) is characterized by a hematoma in the media layer without visible intimal tear, and represents 10-25% of acute aortic syndromes 7, 9
• Penetrating aortic ulcer (Class 3/4) is an ulceration of an atherosclerotic plaque that penetrates the internal elastic lamina, and is more common in elderly patients with advanced atherosclerosis 9, 10

Diagnosis and Imaging

• The European Heart Journal recommends computed tomography (CT) with contrast as the diagnostic technique of choice for acute aortic syndrome, with a sensitivity of 96% for detecting intramural hematoma 7, 8
• Magnetic resonance imaging (MRI) may be useful when differentiating between intramural hematoma and atherosclerotic thickening is difficult 7, 8

Management and Treatment

• The European Society of Cardiology recommends medical treatment, including pain and blood pressure control, for all patients with intramural hematoma 7, 10
• Urgent surgery is indicated for type A intramural hematoma, while initial medical therapy under close surveillance is recommended for type B 7, 10
• Endovascular repair (TEVAR) should be considered for complicated type B intramural hematoma 7, 10