Acute aortic dissection: workup and management
Acute aortic syndrome (dissection, intramural hematoma, penetrating ulcer) is a time-critical diagnosis. Use the Aortic Dissection Detection Risk Score with D-dimer to decide on imaging, confirm with CT angiography, start impulse control immediately (HR <60, SBP <120), and send type A to emergency surgery.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- 2022 ACC/AHA aortic disease guideline: immediate HR and BP control; type A emergency surgery; TEVAR for complicated type B
- Uncomplicated type B with high-risk features can be considered for TEVAR
- ADD-RS ≤1 with D-dimer <500 ng/mL makes dissection very unlikely (ADvISED)
Differential diagnoses
- Type A dissection (ascending aorta) (can't miss)
- Type B dissection (descending aorta)
- Intramural hematoma, penetrating aortic ulcer
- Acute coronary syndrome (can't miss; dissection can involve coronary ostia)
- Pulmonary embolism, ruptured AAA, pericarditis
- Stroke or limb ischemia from branch-vessel malperfusion
02Assess
Risk scores and decision tools
- Aortic Dissection Detection Risk Score (ADD-RS)
- D-dimer <500 ng/mL with ADD-RS ≤1 to rule out
- Stanford (A/B) and DeBakey classification
- Malperfusion assessment: coronary, cerebral, mesenteric, renal, limb
Key history questions
- Abrupt, severe, tearing or ripping chest, back or abdominal pain
- Syncope, focal neurological symptoms, limb pain or numbness
- Hypertension, known aortic aneurysm, bicuspid valve, Marfan or connective tissue disease
- Recent aortic surgery or catheterization; cocaine use
- Family history of aortic disease
Examination findings
- BP in both arms (difference >20 mmHg), pulse deficits
- New diastolic murmur (aortic regurgitation)
- Signs of tamponade or shock
- Focal neurology, limb ischemia, abdominal tenderness (mesenteric ischemia)
03Investigate
Initial investigations
- ECG (exclude STEMI; inferior ST elevation can mean right coronary involvement)
- CT angiography of chest, abdomen and pelvis
- Point-of-care echo for pericardial effusion, aortic root dilation and AR
- CBC, BMP, troponin, lactate, coagulation, type and crossmatch
Advanced investigations
- TEE if CT unavailable or patient unstable for transfer
- MRA for stable patients when CT contrast is contraindicated
04Treat
Immediate management
- IV opioid analgesia
- Esmolol 500 mcg/kg bolus then 50–300 mcg/kg/min (or labetalol) to HR <60 first
- Then add a vasodilator (nicardipine or nitroprusside) to SBP 100–120 mmHg, ideally within 20 minutes
- No antiplatelets or anticoagulants until dissection is excluded
First-line treatment
- Type A: emergency cardiothoracic surgery
- Uncomplicated type B: medical therapy in ICU, then oral beta-blocker and BP control
- Complicated type B (rupture, malperfusion, refractory pain or hypertension, rapid expansion): TEVAR
Second-line treatment
- Beta-blocker intolerance: nondihydropyridine calcium channel blocker for rate control
- Tamponade from type A: avoid pericardiocentesis unless arresting; go to surgery
Specialist referrals
- Cardiothoracic surgery immediately for type A
- Vascular surgery or interventional cardiology for type B
- Transfer to a high-volume aortic center
05Disposition
Admission criteria
- All acute aortic syndromes: ICU
Safe discharge criteria
- Stable type B after the acute phase with BP controlled and imaging surveillance arranged
Follow-up timing
- CT or MRI at 1, 3, 6 and 12 months, then yearly
Patient instructions
- Lifelong BP control (<130/80); avoid heavy lifting and fluoroquinolones
- Screen first-degree relatives if heritable disease suspected
Monitoring
- Arterial line; HR and BP every 5–15 min while titrating
- Urine output, lactate, limb and neurological checks
Clinical pearls and pitfalls
- A normal chest X-ray or mediastinum does not exclude dissection
- Beta-blockade before vasodilators prevents reflex tachycardia that increases aortic shear
- Avoid thrombolysis: dissection can mimic STEMI
RefGuidelines and landmark evidence
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.