From the Guidelines
If a patient with chest pain radiating to the back, hypertension, and mediastinal widening on chest X-ray is not adequately treated, the potential consequence is a high mortality rate, with early mortality rates reported to be 1% to 2% per hour after the onset of symptoms for untreated ascending acute aortic dissection, and medical management associated with a mortality rate of nearly 20% by 24 hours after presentation. The clinical presentation of chest pain radiating to the back, high blood pressure, and mediastinal widening on chest X-ray is highly suggestive of an acute aortic syndrome (AAS), which includes acute aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU) 1.
Key Considerations
- The major cause of early death with AAS is aortic rupture 1.
- Risk factors for AAS include hypertension, family history, and underlying collagen vascular disorders 1.
- Timely diagnosis of AAS is crucial to permit prompt management, as early mortality rates are high for untreated ascending AD 1.
- Medical management of acute ascending AD is associated with a high mortality rate, highlighting the need for prompt and effective treatment 1.
Treatment and Management
- Immediate treatment with blood pressure control using beta-blockers and vasodilators is essential to prevent life-threatening complications 1.
- Surgical repair is often necessary for type A dissections, while medical management may be appropriate for uncomplicated type B dissections 1.
- Imaging studies, such as those described in the ACR Appropriateness Criteria, should be directed toward confirming the presence of AAS, classifying location, and identifying entry and reentry sites 1.
Potential Consequences of Untreated AAS
- Aortic rupture, which is often fatal 1.
- Organ ischemia due to involvement of branch vessels 1.
- Cardiac tamponade 1.
- Severe aortic regurgitation 1.
In summary, the potential consequence of not adequately treating a patient with chest pain radiating to the back, hypertension, and mediastinal widening on chest X-ray is a high risk of mortality and severe complications, emphasizing the need for prompt and effective treatment based on the diagnosis and classification of AAS 1.
From the Research
Potential Consequences of Untreated Aortic Dissection
The potential consequences of not adequately treating a patient with chest pain radiating to the back, hypertension, and mediastinal widening on chest X-ray can be severe. Some possible consequences include:
- High mortality rate, with mortality increasing by 1 to 2% per hour if left untreated 2
- Hemodynamic instability and acute organ failure 3, 4
- Aortic rupture or tamponade, which can be fatal 5
- Stroke or other neurological complications due to decreased blood flow to the brain 3
- Kidney damage or failure due to decreased blood flow to the kidneys 2
Importance of Prompt Diagnosis and Treatment
Prompt diagnosis and treatment are crucial in patients with suspected aortic dissection. Some key points to consider include:
- Early suspicion and diagnosis are critical to prevent mortality and morbidity 4, 5
- Imaging studies such as computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing aortic dissection 5
- Treatment focuses on initial resuscitation, strict blood pressure and heart rate control, and potentially surgical intervention depending on the type and complexity of the dissection 4
- Open surgical repair is often necessary for type A (ascending aorta) aortic dissections, while thoracic endovascular aortic repair may be optimal for type B (descending aorta) dissections 5
Risk Factors and Clinical Presentation
Aortic dissection often occurs in patients with a history of hypertension, and the clinical presentation can be variable. Some key points to consider include: