What is the recommended screening and management approach for patients presenting with B-type symptoms?

From the Guidelines

Patients presenting with B-type symptoms suggestive of aortic dissection should undergo immediate medical evaluation and screening for type B aortic dissection (TBAD), with a focus on pain relief and blood pressure control as the first line of management. The recommended approach begins with a thorough history and physical examination, followed by imaging studies such as CT scans of the chest, abdomen, and pelvis with contrast to evaluate for aortic dissection [ 1 ].

Initial Management

• Medical therapy including pain relief and blood pressure control is recommended in all patients with acute TBAD [ 1 ].
• Beta-blockers (BBs) should be considered as the first-line medical therapy in patients with acute TBAD [ 1 ].
• In patients with complicated acute TBAD, emergency intervention is recommended, with thoracic endovascular aortic repair (TEVAR) as the first-line therapy [ 1 ].

Further Evaluation and Management

• For patients with uncomplicated acute TBAD, TEVAR in the subacute phase (between 14 and 90 days) should be considered in selected patients with high-risk features [ 1 ].
• In patients with chronic TBAD, antihypertensive therapy is recommended, and treatment is indicated in patients with a descending thoracic aortic diameter ≥60 mm who are at reasonable surgical risk [ 1 ].
• The use of fenestrated/branched stent grafts may be considered in patients with chronic post-dissection thoracoabdominal aortic aneurysms when treatment is indicated [ 1 ].

Key Considerations

• Prompt diagnosis and management of TBAD are crucial to prevent morbidity and mortality.
• A systematic approach to evaluation and management, including medical therapy, imaging studies, and potential intervention, is essential for optimal patient outcomes [ 1 ].

From the Research

Screening and Management Approach

For patients presenting with B-type symptoms, the recommended screening and management approach is as follows:

• Immediate imaging with chest computed tomography scan followed by transthoracic echocardiography (TTE) is essential to confirm diagnosis 2
• Medical management is aimed at controlling the heart rate, systolic blood pressure, and pain 2
• Patients with Type B acute aortic dissection should be referred to the vascular surgeons for surgical/endovascular interventions if indicated 2

Diagnostic and Treatment Modalities

• The International Registry of Acute Aortic Dissection (IRAD) has advanced our understanding of acute type B aortic dissection, including temporal classification, risk stratification, and thoracic endovascular aortic repair (TEVAR) 3
• IRAD data has identified risk factors for in-hospital mortality, including increasing age, hypotension/shock, periaortic hematoma, and mesenteric ischemia 4

Complicated Cases

• Acute type B aortic dissection complicated by visceral ischemia has a high risk of mortality, and early diagnosis and intervention are crucial 5
• Endovascular treatment and surgery are options for managing complicated cases, while medical management is associated with higher mortality rates 5, 6

Predictive Model

• A predictive model has been developed to estimate individual risk of in-hospital mortality using variables such as age, hypotension/shock, and mesenteric ischemia 4
• This model can assist physicians in choosing management options and informing patients and their families 4