From the Guidelines
To exclude aortic dissection in a patient with chest pain, urgent and definitive imaging of the aorta using CT angiography is recommended due to its high sensitivity and specificity, as evidenced by a study published in 2015 1. When evaluating a patient with suspected aortic dissection, it is crucial to start with a thorough history and physical examination, focusing on risk factors like hypertension, Marfan syndrome, and family history of aortic disease.
- Assess for classic symptoms such as sudden, severe, tearing chest or back pain.
- Vital signs should be checked for hypertension or hypotension, and examine for pulse deficits, new murmurs, or neurological deficits. Laboratory tests should include cardiac biomarkers, D-dimer (which is often elevated in dissection), and basic metabolic panel.
- Imaging is crucial, with CT angiography of the chest and abdomen being the gold standard due to its high sensitivity and specificity of 99% and 100% respectively, as reported in a Class II large retrospective study 1. Alternatives include transesophageal echocardiography, MRI, or aortography if CT is contraindicated.
- For stable patients with low clinical suspicion, a normal D-dimer may help exclude dissection, however, if clinical suspicion is moderate to high, proceed directly to advanced imaging regardless of D-dimer results, as suggested by guidelines from 2010 1. While awaiting diagnosis, control blood pressure (target systolic 100-120 mmHg) using IV beta-blockers like labetalol (10-20 mg IV) or metoprolol (5 mg IV), followed by additional agents if needed.
- Pain should be managed with IV opioids, and remember that ECG changes are non-specific in dissection, and a normal ECG does not rule it out, as stated in the 2010 guidelines 1.
From the Research
Excluding Aortic Dissection in Patients with Chest Pain
To exclude aortic dissection in a patient with chest pain, several diagnostic approaches can be considered:
- A thorough history and physical examination to identify high-risk patients and those with symptoms suggestive of aortic dissection, such as chest and back pain that progresses downward 2
- The use of imaging tests, including:
- Computed Tomography (CT) scans, which can confirm the diagnosis of aortic dissection and are particularly useful in high-risk patients, even if laboratory tests such as the D-dimer assay are unremarkable 3
- Transesophageal echocardiography, which can establish the diagnosis of aortic dissection and identify alternate cardiovascular pathology responsible for the symptoms in patients without dissection 4
- Aortography, which can be used to confirm the diagnosis of aortic dissection, although it is less commonly used than CT scans and echocardiography 2, 4
- Maintaining a high level of suspicion for aortic dissection, even in patients with initial negative imaging studies, particularly if they have an ascending aortic aneurysm and recent onset chest pain 5
- Considering early operation in patients with suspected type A aortic dissection, even if initial imaging studies are negative, due to the high risk of mortality associated with this condition 5
Laboratory Tests
Laboratory tests, such as the D-dimer assay, may be used to support the diagnosis of aortic dissection, but they should not be relied upon exclusively, as they may not always be abnormal in patients with dissection 3, 6
- The D-dimer assay may be useful in some cases, but it is not a definitive test for aortic dissection and should be interpreted in conjunction with clinical findings and imaging results 3
Clinical Presentation
Aortic dissection can present with a variety of clinical manifestations, including:
- Chest pain, which is the most common symptom 4, 6
- Back pain, which can occur in conjunction with chest pain or as a separate symptom 2, 4
- Syncope, which can occur in some patients with aortic dissection 4, 5
- Abdominal pain, anuria, pulse deficits, and acute congestive heart failure, which can also occur in patients with aortic dissection 6