AHA/ACC Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (2010)

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Commentary by Reed E. Pyeritz, MD, PhD

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About aortic dissection

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About aortic dissection

An aortic dissection is a tear in the inner layer of the aortic wall. This tear allows blood to enter and separate the inner and outer layers of the vessel. In addition, dissection can weaken the outer wall, resulting in instability or rupture; occlusion (blockage) of aortic branch vessels causing myocardial infarction, stroke, kidney failure, bowel ischemia, paraplegia or limb ischemia; and disruption of the aortic valve, resulting in valvular insufficiency and congestive heart failure.

Approximately 10,000 people experience aortic dissections annually, so it is likely that triage staff will encounter this condition in the emergency department.

Aortic dissection, sometimes referred to as “the great imitator,” can look like many other more benign ailments. Symptoms of aortic dissection can be variable, relatively minor, and nonspecific. Chest pain is the most common symptom, but pain can also occur in the back and/or abdomen. The pain may be described as severe or vague, constant or intermittent, migratory, tearing, tightness, or fullness. Other signs and symptoms may include cardiovascular instability, pulselessness, parathesia, paralysis, syncope, or a sense that “something is terribly wrong.”

The most definitive tests for aortic dissection are CT scan, TEE, and MRI.

The test that is most readily available, expertly performed, and expertly interpreted should be chosen. It is important to understand that a normal chest x-ray does not rule out aortic dissection.

Who Is At Risk?

Many people may be at risk of aortic disease and not even know it. Risk factors for aortic disease, aneurysm and dissection include:

Red Flags During Triage and Assessment

During triage and assessment, a number of clinical signs – “red flags” – should alert triage staff to the possibility of aortic dissection. The ability to recognize these signs may make the difference between securing immediate life-saving interventions and waiting until it is too late for the patient.

The sections that follow describe red flags to watch for during triage and assessment.