AORTIC DISSECTION

Aortic Dissection Inciting event is a tear in the aortic intima. Propagation of the dissection can occur proximal (retrograde) or distal (antegrade) to the initial tear, involve the aortic valve, or branches of the thoracic and/or abdominal aorta. Propagation of the dissection is responsible for clinical manifestations that can include aortic regurgitation, cardiac tamponade, and end-organ ischemia (coronary, cerebral, spinal, or visceral).

Aortic Dissection International Registry of Acute Aortic Dissection (IRAD) – 2.6 to 3.5 per 100,000 person-years – Most likely 60 – 80 year old men – Risk factors (especially for younger patients): Preexisting aortic aneurysm Collagen disorders, Turner syndrome, inflammatory diseases Bicuspid aortic valve Aortic coarctation Previous aortic valve replacement (5% of all, 12% under 50) Cocaine usage within last 24 hours

Aortic Dissection Symptoms: – “Tearing” abdominal or back pain, much more common in Type B – Type A more likely to present with anterior chest pain – 73% of patients with Type A presented with abrupt onset of chest pain and more often sharp than tearing – Can be alone or accompanied by syncope, CVA, MI, HF

Aortic Dissection Blood pressure at presentation: – Most patients with an aortic dissection have a h/o HTN the blood pressure is quite variable at presentation with acute aortic dissection – With a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension. – In those who present with distal aortic dissections, 70% present with hypertension while 4% present with hypotension.

Clinical Manifestations Study found that 96% of aortic dissections could be identified based on : – Abrupt onset of thoracic or abdominal pain with a sharp, tearing or ripping character – Mediastinal or aortic widening on chest radiograph – A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm) >83% had variation in pulse or BP differential 77% had 2 of the 3 variables 39% had CXR abnormalities

Clinical Pearl **If a patient presents with chest pain and neurologic symptoms, suspect Aortic Dissection!