What is the initial management for a patient suspected of having an aortic syndrome?

Initial Management of Suspected Aortic Syndrome

For patients suspected of having an aortic syndrome, immediate assessment using the Aortic Dissection Detection (ADD) score, pain control, blood pressure management with target systolic BP 100-120 mmHg and heart rate <60 beats/min, and rapid transfer to a center with 24/7 aortic imaging and cardiac surgery capabilities is recommended. 1

Initial Assessment

• Use the Aortic Dissection Detection (ADD) score to assess pre-test probability of aortic syndrome, with patients scoring ≥1 considered high-risk 1
• High-risk conditions include Marfan syndrome or other connective tissue diseases, family history of aortic disease, known aortic valve disease, known thoracic aortic aneurysm, and previous aortic manipulation 1
• High-risk pain features include abrupt onset, severe intensity, and ripping/tearing quality 1
• High-risk examination features include pulse deficit, systolic blood pressure difference between limbs, focal neurological deficit, new aortic diastolic murmur, and hypotension/shock 1
• Perform ECG to rule out other causes of chest pain, though it is usually normal in aortic syndromes 1
• Focused echocardiography (FoCUS) may be helpful to support the diagnosis, especially when ECG shows signs of myocardial ischemia 1

Initial Management

Pain Control

• Provide adequate pain relief with intravenous opiates to reduce sympathetic stimulation 2, 3

Blood Pressure and Heart Rate Control

• Target heart rate <60 beats/min and systolic blood pressure between 100-120 mmHg in the absence of neurological complications 1
• Administer intravenous beta-blockers as first-line treatment (first choice) 1, 3
• Start beta-blockers before other anti-hypertensive drugs to avoid reflex tachycardia 1
• If additional blood pressure control is needed, add nitrates, sodium nitroprusside, or calcium channel blockers 1
• If beta-blockers are contraindicated, use non-dihydropyridine calcium channel blockers 1, 2

Diagnostic Imaging

• ECG-gated CT angiography from neck to pelvis is the first-line imaging technique for suspected acute aortic syndrome 1, 2
• In unstable patients who cannot be transferred for CT, transesophageal echocardiography (TOE) is recommended 1, 2
• Transthoracic echocardiography (TTE) is recommended as an initial imaging investigation 1

Transfer Considerations

• Patients with a very high probability of aortic dissection (ADD score ≥1) should be transferred to a center with 24/7 available aortic imaging (CT, MRI, TTE, TOE) and cardiac surgery capabilities 1
• Transfer to a non-surgical center for imaging before transfer to a facility with cardiac surgery should be avoided when the probability of aortic dissection is high 1
• In some regions, aortic imaging and cardiac surgery may be activated during transfer, with the patient admitted directly to radiology before proceeding to the operating theater 1

Management of Complications

• In the case of complications (stroke, tamponade, mesenteric ischemia, acute aortic regurgitation, MI, cardiogenic shock), treatment in the pre-hospital setting is limited to life support 1
• For type A aortic dissection (involving the ascending aorta), emergency surgical consultation and immediate surgical intervention is recommended 2, 3
• For complicated acute Type B dissection (involving only the descending aorta), emergency intervention with thoracic endovascular aortic repair (TEVAR) is recommended 2

Common Pitfalls and Caveats

• Aortic dissection is suspected at initial presentation in only 20% of those with a final diagnosis of aortic dissection, making it crucial to maintain a high index of suspicion 1, 4
• Never administer antithrombotic therapy (aspirin, P2Y12 inhibitors, anticoagulants) when aortic dissection is suspected 1, 5
• Avoid transferring patients to facilities without cardiac surgery capabilities when aortic dissection is highly suspected 1
• Do not use vasodilators without prior beta-blockade as this can lead to reflex tachycardia and increased aortic wall stress 3