In a patient over 60 with hypertension, smoking history, possible connective‑tissue disease and sudden severe tearing chest or back pain, how should I diagnose and manage a suspected aortic dissection?

Diagnosis and Management of Suspected Aortic Dissection

In a patient over 60 with hypertension, smoking history, possible connective tissue disease, and sudden severe tearing chest or back pain, immediately transfer to an intensive care unit, initiate IV beta-blockers to target heart rate ≤60 bpm and systolic blood pressure 100-120 mmHg, and obtain urgent CT angiography to confirm the diagnosis—if Type A dissection is confirmed, proceed directly to emergency surgical repair. 1, 2

Immediate Clinical Recognition

The clinical presentation is critical for rapid diagnosis:

• Pain characteristics: Abrupt onset with maximum intensity at the beginning distinguishes dissection from myocardial infarction, which builds gradually 1
• Pain location: Retrosternal pain suggests proximal (Type A) dissection involving the ascending aorta, while interscapular or back pain indicates distal (Type B) dissection 1
• Risk factors: Your patient's profile (male in 60s with hypertension and smoking) matches the typical presentation; hypertension is particularly associated with distal dissections 1
• Atypical presentations: Up to 20% present with syncope without typical pain, and cardiac failure from severe aortic regurgitation may dominate the clinical picture 1
• Physical examination findings: Check for pulse deficits, limb ischemia, signs of cardiac tamponade (hypotension, syncope), oliguria/anuria suggesting renal artery involvement, or a diastolic murmur indicating aortic regurgitation 3, 1

Critical Initial Management Steps

Hemodynamic Control (First Priority)

Before any imaging, begin aggressive blood pressure and heart rate control:

1. Beta-blockers as first-line therapy: Administer IV beta-blockers immediately (propranolol 0.05-0.15 mg/kg every 4-6 hours, esmolol loading dose 0.5 mg/kg over 2-5 minutes followed by infusion 0.10-0.20 mg/kg/min, metoprolol, or labetalol) 3, 1

   • Target heart rate ≤60 beats per minute 1, 2
   • Beta-blockers reduce the force of left ventricular ejection (dP/dt), which prevents further weakening of the arterial wall 3

2. Add vasodilators only after beta-blockade: If systolic blood pressure remains >120 mmHg despite adequate beta-blockade, add IV sodium nitroprusside (initial dose 0.25 μg/kg/min, titrate to systolic BP 100-120 mmHg) 3, 1

   • Critical pitfall: Never use vasodilators before beta-blockers, as they increase the force of left ventricular ejection and worsen the dissection 3

3. Alternative agents: In patients with bronchial asthma or other beta-blocker contraindications, use calcium channel blockers (verapamil, diltiazem, or nifedipine) 3

4. Pain control: Administer morphine sulfate for analgesia and to reduce sympathetic stimulation 3, 1, 2

5. Monitoring: Place an arterial line (preferably right radial artery) for invasive blood pressure monitoring; check both arms to rule out pseudo-hypotension from brachiocephalic trunk obstruction 3

Diagnostic Imaging Strategy

Every patient with suspected aortic dissection requires urgent definitive imaging 1:

• CT angiography is first-line in hemodynamically stable patients, with sensitivity and specificity near 100% 3, 1, 4
• Transesophageal echocardiography (TEE) has sensitivity 98-100% and specificity 95-100%, and can be performed at bedside in unstable patients 3, 5
• Transthoracic echocardiography (TTE) has lower sensitivity (60-80%) but can rapidly identify cardiac tamponade in profoundly unstable patients 3, 2
• Avoid using multiple sequential imaging techniques—this wastes critical time 3

Important caveat: If the patient presents with ECG signs of myocardial ischemia, obtain imaging before administering thrombolytics, as thrombolytic therapy can be catastrophic in aortic dissection 1

Type-Specific Definitive Management

Type A Dissection (Ascending Aorta Involvement)

Type A dissection is a surgical emergency requiring immediate intervention 3, 1:

• Obtain urgent surgical consultation as soon as diagnosis is confirmed 1, 2
• Emergency surgical repair should not be delayed, especially with hypotension, pulmonary edema, or low flow 3
• Surgical options include resection of aneurysmal aorta, aortic valve resuspension, and composite graft implantation in the ascending aorta 1, 2
• Early surgery reduces in-hospital mortality (absolute risk reduction 5.9%) compared to medical therapy 3

Type B Dissection (Descending Aorta, Distal to Left Subclavian)

Type B dissection is initially managed medically unless complications develop 3, 1:

• Continue aggressive blood pressure and heart rate control 2
• Emergency intervention (preferably TEVAR—thoracic endovascular aortic repair) is indicated for: malperfusion syndrome, intractable pain despite optimal medical therapy, rapid aortic expansion, periaortic hematoma, or inability to control blood pressure 6

Special Considerations for Your Patient

Given the possible connective tissue disease:

• Patients with Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, or bicuspid aortic valves are at increased risk for dissection at younger ages 1
• These patients require lifelong beta-blocker therapy for prevention of dissection 1, 2

Critical Pitfalls to Avoid

1. Never perform pericardiocentesis before surgical intervention in patients with cardiac tamponade—relieving intrapericardial pressure precipitates recurrent bleeding 3, 6

2. Intra-aortic balloon counterpulsation is absolutely contraindicated in acute severe aortic regurgitation, as augmentation of aortic diastolic pressure worsens regurgitant volume 3

3. Do not delay transfer to a specialized center with surgical backup while pursuing extensive diagnostic workup 6

4. Avoid vasopressors in hypotensive patients when possible; prioritize volume resuscitation as hypotension may result from blood sequestration in the false lumen or pleural/pericardial space 3, 6

5. D-dimer may be helpful (level <500 ng/mL makes dissection unlikely) but should never be used alone to rule out dissection 6