›High-sensitivity troponin for concurrent myocardial ischemia evaluation
›Troponin elevation does not exclude dissection
›INR and aPTT for baseline and anticoagulant exposure
›Anticoagulation status informs bleeding risk and procedural planning
›Type and screen
›Crossmatch if hypotension, hemothorax concern, or transfer to surgery likely
D-dimer and biomarkers
›Biomarker adjuncts
›D-dimer in selected low to intermediate risk patients
›Time from symptom onset documentation
›False-negative risk with delayed presentation and limited dissection extent
›Pregnancy test when applicable
›Imaging and medication selection implications
06Diagnostic Tests/dt58
Scoring Systems
›Risk stratification tools
›Aortic Dissection Detection Risk Score (ADD-RS)
›High-risk conditions category
›Marfan syndrome or other connective tissue disease
›Family history of aortic disease
›Known aortic valve disease
›Recent aortic manipulation
›Known thoracic aortic aneurysm
›High-risk pain features category
›Abrupt onset
›Severe intensity
›Ripping or tearing quality
›High-risk exam features category
›Perfusion deficit
›Focal neurologic deficit
›New aortic regurgitation murmur
›Hypotension or shock
›Scoring interpretation
›0 points low risk features absent
›1 point intermediate risk
›2 to 3 points high risk
›ADD-RS plus D-dimer strategies
›Selected use in low to intermediate risk patients to reduce unnecessary CTA
›D-dimer threshold commonly 500 ng/mL for rule-out strategies in studies
MRI
›MRI and MRA of the aorta
›Indications
›Hemodynamically stable with contraindication to iodinated contrast
›Need to avoid ionizing radiation in selected patients when feasible
›Limitations
›Limited availability in unstable patient
›Longer acquisition time
›Diagnostic performance
›High sensitivity and specificity reported in acute aortic syndrome when protocols optimized
CT
›CT angiography
›Protocol essentials
›Arterial phase CTA of chest with extension to abdomen and pelvis for extent and malperfusion
›ECG-gating consideration for ascending aorta to reduce motion artifact
›Key findings
›Intimal flap
›True and false lumen
›Branch vessel involvement
›Pericardial effusion or hemothorax
›Diagnostic performance
›High sensitivity and specificity for acute aortic syndrome in contemporary practice
›Contrast considerations
›Creatinine elevation is not an automatic contraindication in life-threatening suspected dissection
Ultrasound
›Bedside ultrasound applications
›Cardiac POCUS
›Pericardial effusion
›Tamponade physiology
›Aortic root dilation
›Gross aortic regurgitation clues
›Abdominal aorta ultrasound
›Aneurysm screening
›Limited sensitivity for thoracic dissection
›Role limitations
›Negative ultrasound does not exclude dissection
›Use to detect complications and guide stabilization
07Disposition/dispo24
Type A suspected or confirmed
›Type A disposition
›ICU-level care and emergent surgical pathway
›Immediate cardiothoracic surgery involvement
›Transfer criteria
›No on-site cardiothoracic surgery
›Need for aortic surgery or ECMO-capable center
›Pre-transfer stabilization priorities
›Anti-impulse therapy ongoing with arterial line when feasible
›Analgesia and sedation adequate to minimize sympathetic surge
Type B suspected or confirmed
›Type B disposition
›Uncomplicated Type B
›ICU or step-down based on hemodynamics and pain control needs
›Medical management with strict anti-impulse targets
›Complicated Type B
›Persistent or recurrent pain despite therapy
›Malperfusion syndrome
›Rapid expansion or impending rupture imaging features
›Hypotension or shock
›Urgent vascular surgery or endovascular team involvement
Rule-out and alternative diagnoses
›Rule-out disposition
›If dissection excluded and alternative diagnosis identified
›Disposition per alternate diagnosis risk
›If dissection excluded but ongoing high-risk symptoms
›Observation and reconsideration of imaging quality and differential
08Treatment/t69
Analgesia and sympathetic control
›Pain and agitation control
›Opioid analgesia
›Fentanyl IV 25 to 50 micrograms
›Repeat every 5 to 10 minutes to pain control
›Monitor for chest wall rigidity at high cumulative doses
›Morphine IV 2 to 4 mg
›Repeat every 5 to 15 minutes as needed
›Anxiolysis adjunct
›If severe anxiety or ventilator dyssynchrony, titrate benzodiazepine cautiously
Heart rate control first
›Beta-blockade strategy
›Esmolol IV
›Bolus 500 micrograms/kg over 1 minute
›If hypotension risk, omit bolus and start infusion
›Infusion 50 micrograms/kg/min
›Titration 25 to 50 micrograms/kg/min every 5 to 10 minutes
›Maximum 300 micrograms/kg/min
›Labetalol IV
›Bolus 10 to 20 mg over 2 minutes
›Repeat 20 to 80 mg every 10 minutes
›Maximum 300 mg total
›Infusion option 0.5 to 2 mg/min
›Titration to heart rate and systolic target
›Contraindications and alternatives
›If severe bronchospasm or decompensated heart failure, consider short-acting non-dihydropyridine calcium channel blocker
›Diltiazem IV bolus 0.25 mg/kg over 2 minutes
›Infusion 5 to 15 mg/hour titrated to heart rate
Blood pressure control after beta-blockade
›Vasodilator strategy
›Nicardipine IV
›Start 5 mg/hour
›Titration 2.5 mg/hour every 5 to 15 minutes
›Maximum 15 mg/hour
›Clevidipine IV
›Start 1 to 2 mg/hour
›Double dose every 90 seconds until approaching goal
›Then increase by smaller increments every 5 to 10 minutes
›Typical maximum 16 mg/hour
›Nitroprusside IV
›Use only after adequate beta-blockade
›Start 0.25 micrograms/kg/min
›Titration every 5 minutes to goal
›Maximum 10 micrograms/kg/min
›Toxicity considerations
›Cyanide and thiocyanate accumulation risk with high dose or prolonged infusion
Hypotension and shock pathways
›Shock management
›Hemorrhage or rupture concern
›Balanced blood product resuscitation when indicated
›Permissive hypotension consideration until surgical control if actively exsanguinating
›Tamponade concern
›Urgent surgical pathway for Type A with tamponade physiology
›Pericardiocentesis only as bridge in extremis with immediate surgical plan
›Malperfusion concern
›Urgent endovascular or surgical reperfusion planning
›Avoid excessive BP lowering that worsens organ ischemia
Antithrombotics and thrombolysis precautions
›Antithrombotic safety
›If dissection suspected, avoid empiric fibrinolysis for presumed STEMI until excluded when features present
›Aortic imaging priority when dissection red flags coexist with ischemic ECG changes
›If patient already anticoagulated, reversal planning in surgical candidates
›Agent-specific reversal aligned with institutional protocol
Definitive management pathways
›Definitive management
›Stanford Type A
›Emergent surgical repair as standard of care
›Anti-impulse therapy continued until operative control
›Stanford Type B
›Uncomplicated
›Medical therapy with strict targets
›Serial exams for malperfusion development
›Complicated
›TEVAR evaluation and treatment when anatomy suitable
›Open surgery when TEVAR not feasible or failed
09Special Populations/sp25
Pregnancy
›Pregnancy considerations
›Risk context
›Increased risk in connective tissue disorders and late pregnancy or postpartum
›Imaging selection
›CTA when life-threatening suspicion outweighs radiation risk
›MRI or MRA when stable and available to reduce radiation exposure
›Medication considerations
›Beta-blockers with fetal growth monitoring considerations
›Avoid nitroprusside when possible due to fetal toxicity concern
Geriatric
›Geriatric considerations
›Presentation differences
›Higher likelihood of atypical symptoms and delayed presentation
›Medication sensitivity
›Higher risk of hypotension with aggressive titration
›Slower titration and close perfusion monitoring
›Comorbidity impact
›Chronic kidney disease and contrast risk trade-offs favor life-saving imaging
Pediatrics
›Pediatric considerations
›Epidemiology context
›Rare, often associated with congenital heart disease or heritable aortopathy
›Imaging and sedation
›Weight-based contrast dosing and pediatric protocol CTA or MRI selection
›Sedation planning for motion control and hemodynamic stability
›Weight-based hemodynamic management
›Anti-impulse targets individualized to age and baseline BP percentiles
10Background/b24
Epidemiology
›Epidemiology summary
›Incidence context
›Acute aortic dissection is uncommon but high mortality without rapid diagnosis
›Risk factor prevalence
›Hypertension as the most common associated condition in adults
›Classification prevalence
›Stanford Type A proportion substantial and time-critical for surgery
Pathophysiology
›Mechanisms and classification
›Intimal tear with blood tracking into media
›True lumen compression by false lumen expansion
›Stanford classification
›Type A involves ascending aorta
›Type B confined to descending aorta distal to left subclavian origin
›DeBakey classification
›Type I ascending plus descending
›Type II ascending only
›Type III descending with variable extent
Therapeutic Considerations
›Rationale for therapy
›Anti-impulse therapy reduces dP/dt and shear stress
›Beta-blockade reduces heart rate and contractility
›Vasodilators reduce afterload after rate control achieved
›Definitive repair principles
›Type A requires surgical repair to prevent rupture and tamponade
›Complicated Type B often benefits from endovascular repair to treat rupture or malperfusion
11Patient Discharge Instructions/pdi17
Copy discharge instructions
›Discharge guidance after dissection exclusion or stable chronic aortic disease plan
›Return now for red flags
›New or worsening chest pain
›New back or abdominal pain
›Fainting or near-fainting
›New weakness, numbness, trouble speaking, or vision changes
›New shortness of breath
›New cold, painful, weak, or numb arm or leg
›Activity and blood pressure guidance
›Avoid heavy lifting or straining until cleared
›Home blood pressure checks if advised
›Medications
›Take prescribed blood pressure medicines exactly as directed
›Do not stop beta-blocker suddenly without clinician advice
›Follow-up
›Follow-up with primary care and specialist as arranged
›Bring imaging reports to follow-up appointments
12References/r14
Clinical guidelines
›Professional society guidelines
›2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease
›Acute aortic syndrome sections for imaging and anti-impulse therapy recommendations
›European Society of Cardiology aortic disease guidance
›Acute aortic syndrome diagnostic and treatment recommendations
›ESC Peripheral Arterial and Aortic Diseases guideline framework
›Integrated approach across aortic syndromes and follow-up
Evidence-based sources
›Key evidence and decision tools
›ADvISED study on ADD-RS combined with D-dimer for risk stratification
›Rule-out strategy research in low to intermediate risk groups
›Meta-analyses of D-dimer for acute aortic syndromes
›Sensitivity and specificity estimates and limitations
›Decision-analytic modelling for ADD-RS and D-dimer strategies
›Impact of prevalence and selection on imaging yield
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
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