What is the diagnostic workup for aortic dissection?

From the Guidelines

The diagnostic workup for aortic dissection should begin with a thorough history and physical examination, followed by immediate diagnostic imaging with CT angiography as the first-line modality, due to its high sensitivity and specificity, as recommended by the most recent guidelines 1. The workup should focus on risk factors and clinical presentation, including symptoms such as chest or back pain, and signs of cardiac tamponade or aortic regurgitation.

• Immediate diagnostic imaging is essential, with CT angiography being the preferred modality due to its high sensitivity (95-100%) and specificity (95-98%) 1.
• Alternatives include transesophageal echocardiography, MRI, or aortography if CT is unavailable or contraindicated.
• Laboratory tests should include complete blood count, basic metabolic panel, cardiac enzymes, and type and cross for potential blood transfusion.
• While awaiting diagnosis, immediate management includes pain control with IV opioids (morphine 2-4mg IV), blood pressure control targeting systolic BP 100-120 mmHg using IV beta-blockers (esmolol 50-200 μg/kg/min or labetalol 10-20mg IV followed by 20-80mg every 10 minutes) as first-line agents, followed by vasodilators like nicardipine (5-15 mg/hr) if needed, as recommended by recent guidelines 1.
• Continuous cardiac monitoring, two large-bore IV access lines, and frequent vital sign checks are essential. This aggressive diagnostic and stabilization approach is critical because aortic dissection has a mortality rate of 1-2% per hour during the first 24-48 hours if left untreated, with risk factors including hypertension, connective tissue disorders, bicuspid aortic valve, and family history 1.

From the Research

Diagnostic Workup for Aortic Dissection

The diagnostic workup for aortic dissection involves various imaging modalities to quickly and accurately diagnose this life-threatening condition.

• Computed tomographic angiography (CTA) is considered the established gold standard test 2
• Transesophageal echocardiography (TEE) allows for rapid and safe assessment of aortic dissection and is particularly useful in diagnosing dissection of the ascending aorta 3, 2
• Transthoracic echocardiogram (TTE) can also be used to suggest the presence of aortic dissection, especially when clinical suspicion is high 2
• Magnetic resonance angiography is another imaging modality used to establish the diagnosis of aortic dissection 4
• Point of care ultrasonography (POCUS) is a rapid method of diagnosis that can be used to obtain a timely diagnosis 4
• Helical computed tomography and electron-beam computed tomography are new imaging techniques that allow for a better and earlier diagnosis of aortic diseases even in emergency situations 5

Imaging Modalities

Different imaging modalities have their own advantages and disadvantages.

• TEE is useful in emergency situations and can quickly diagnose dissection of the ascending aorta 3
• CTA is the gold standard test but may not always be foolproof 2
• POCUS is a rapid method of diagnosis but may not be widely utilized in current clinical practice 4

Clinical Considerations

Clinical considerations play a crucial role in the diagnostic workup of aortic dissection.

• Clinical suspicion for dissection should be high, especially in patients with complications such as aortic regurgitation 2
• The patient's presentation may be atypical, and some cases of aortic dissection may be painless 4
• Determining the right time for elective surgery is crucial to decrease urgent surgical procedures on the ascending aorta 5