What is the diagnosis and treatment for aortic dissection?

From the Guidelines

Aortic dissection is a life-threatening emergency that requires immediate medical attention, with treatment depending on the location and severity of the dissection, and prioritizing emergency surgery for type A dissections and medical management for type B dissections. The condition occurs when the inner layer of the aorta tears, allowing blood to flow between the layers of the aortic wall, forcing them apart. According to the most recent guidelines 1, the management of aortic dissection should focus on reducing morbidity, mortality, and improving quality of life.

Key Considerations

• The location and severity of the dissection determine the treatment approach, with type A dissections (involving the ascending aorta) requiring emergency surgery and type B dissections (affecting only the descending aorta) often managed medically with blood pressure control.
• Initial treatment includes aggressive blood pressure reduction using intravenous beta-blockers like labetalol or esmolol, targeting a systolic blood pressure of 100-120mmHg, as recommended by the European Society of Cardiology 1.
• Pain control with opioid analgesics is essential, and long-term management includes oral antihypertensives, typically beta-blockers, and regular imaging surveillance with CT or MRI every 6-12 months.
• Patients should permanently avoid heavy lifting and extreme physical exertion to prevent further damage to the aortic wall.

Diagnosis and Management

• The diagnosis of aortic dissection is often challenging, but timely identification is crucial to permit prompt management, with early mortality rates reported to be 1% to 2% per hour after the onset of symptoms for untreated ascending AD 1.
• Imaging studies, such as computed tomography angiogram (CTA), transesophageal echocardiogram (TEE), transthoracic echocardiogram (TTE), and magnetic resonance angiogram (MRA), play a critical role in confirming the presence of aortic dissection, classifying the location, and identifying entry and reentry sites.
• The American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines recommends urgent surgical consultation for all patients diagnosed with thoracic aortic dissection, regardless of the anatomic location 1.

Treatment Outcomes

• Emergency surgery for type A dissections can reduce mortality rates, with surgery reducing 1-month mortality from 90% to 30% 1.
• Medical management of acute ascending AD is associated with a mortality rate of nearly 20% by 24 hours after presentation, 30% by 48 hours, 40% to 70% by day 7, and 50% by 1 month 1.
• The condition occurs due to weakening of the aortic wall, often from chronic hypertension, genetic disorders like Marfan syndrome, or atherosclerosis, with classic symptoms including sudden, severe chest or back pain described as tearing or ripping, which may migrate as the dissection extends.

From the Research

Definition and Symptoms of Aortic Dissection

• Aortic dissection is a serious and life-threatening condition that requires prompt, effective management 2.
• The most prevalent symptom is excruciating chest pain 3.
• Clinical presentation is variable and can mimic any number of medical and surgical conditions 3.

Treatment and Management

• Essential treatment includes rapid initiation of pharmacologic agents to control hypertension 3.
• Aortic dissection involving the ascending aorta also necessitates immediate surgical repair 3.
• Medical management for type B aortic dissections requires aggressive blood pressure and heart rate control to minimize further dissection extension and to restore perfusion to vital organs 4.
• Current guidelines recommend β-blockers as first-line therapy, however do not differentiate an ideal agent for use 4.
• Immediate medical management is aimed at controlling the heart rate (60-80 beats/min), systolic blood pressure (100-120 mmHg) and pain 5.

Specific Treatment Options

• Esmolol can be used for heart rate control in patients with acute aortic dissection, with a lenient heart rate goal achieved in most patients 2.
• Labetalol combination therapies can be used for type B aortic dissections, with a non-statistical significant higher incidence of hemodynamic instability compared to an esmolol combination regimen 4.
• Endovascular aortic repair can be used to treat postpartum aortic dissection, with placement of an aortic stent graft under imaging guidance 6.

Diagnosis and Referral

• Immediate imaging with chest computed tomography scan followed by transthoracic echocardiography is essential to confirm diagnosis 5.
• Patients with Type A acute aortic dissection should immediately be referred to the cardiothoracic surgeons for emergency aortic surgery 5.
• Patients with Type B acute aortic dissection should be referred to the vascular surgeons for surgical/endovascular interventions if indicated 5.