An Evidence-Based Approach To Acute Aortic Syndromes

Aortic dissection is an uncommon but deadly disease. Patients with high-risk features should have an evaluation for possible aortic dissection. Current biomarkers, especially D-dimer, have shown promise in the evaluation of aortic dissection, but they should not be used alone to rule out aortic dissection. While advanced imaging options have been shown to have excellent sensitivity and specificity, if clinical suspicion for aortic dissection is high, a negative first study should be followed with another diagnostic modality. Further studies are needed to provide better algorithmic pathways and treatment strategies in the evaluation of aortic dissection.

 Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome

Conclusion Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer.

Acute Aortic Syndromes

The term “acute aortic syndrome” (AAS) has been used to describe a mixed group of thoracic aortic disorders that characteristically present with a typical combination of signs and symptoms. The most distinctive presenting symptom is aortic pain, which is often described as sharp, tearing, or ripping. Although there are several pathophysiologic entities that can present as AAS, occasionally one process can precede another or occasionally they may. Importantly though, all can be life-threatening and require immediate medical attention.

Acute Aortic Syndrome

Here is a lecture from the very talented and entertaining Prof Joe Nameth, who spoke on the topic of Chest Pain Catastrophies at EMCORE London in June 2023. This segment of his talk, looks at Acute Aortic Syndrome.

Acute Aortic Syndrome Revisited

The term acute aortic syndrome (AAS), coined in 1998 and fully described in 2001, refers to a heterogeneous group of patients with a common set of signs and symptoms, the foremost of which is aortic pain. This syndrome embraces a cluster of 4 acute aortic conditions: classic dissection (CD), intramural hematoma (IHM), penetrating aortic ulcer (PAU), and incomplete dissection (ID).

Acute Aortic Syndrome: Aortic Dissection, Intramural Hematoma and Penetrating Ulcer

The term Acute Aortic Syndrome (AAS) is used to describe three closely related emergency entities of the thoracic aorta: classic Aortic Dissection (AD), Intramural Hematoma (IMH) and Penetrating Atherosclerotic Ulcer (PAU). Clinically these conditions are indistinguishable. CT is the most accurate imaging modality for the initial diagnosis, differentiation and staging. This review will discuss the imaging features and important pitfalls.

Acute aortic syndromes and aortic emergencies

The term acute aortic syndrome (AAS) encompasses three pathological entities; aortic dissection (AD; 85–95% of AAS), penetrating aortic ulcer (PAU; 2–7%) and intramural hematoma (IMH; 0–25%). Even though other conditions that represent aortic emergencies like trauma, iatrogenic/septic pseudoaneurysms, and ruptured atherosclerotic aneurysm have similar signs and symptoms, the term AAS is typically reserved for the aforementioned triad of AD, PAU and IMH entities.

Acute aortic syndromes and aortic emergencies

The term acute aortic syndrome (AAS) encompasses three pathological entities; aortic dissection (AD; 85–95% of AAS), penetrating aortic ulcer (PAU; 2–7%) and intramural hematoma (IMH; 0–25%). Even though other conditions that represent aortic emergencies like trauma, iatrogenic/septic pseudoaneurysms, and ruptured atherosclerotic aneurysm have similar signs and symptoms, the term AAS is typically reserved for the aforementioned triad of AD, PAU and IMH entities. These conditions have a common clinical presentation and are typically associated with acute chest or back pain.

Aortic Dissection and Other Acute Aortic Syndromes: Diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression

Acute aortic dissection is the prototype of acute aortic syndromes (AASs), which include intramural hematoma, limited intimal tear, penetrating atherosclerotic ulcer, traumatic or iatrogenic aortic dissection, and leaking or ruptured aortic aneurysm. The manifestation is usually sudden and catastrophic with acutely severe tearing chest or back pain. However, clinical symptoms do not allow distinction between AAS types and other acute pathologic conditions. Diagnostic imaging is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of AASs.

Aortic Dissection and Related Aortic Syndromes

Acute aortic syndromes encompass a number of life-threatening aortic emergencies. These include aortic dissection, penetrating atherosclerotic ulcer, intramural hematoma, and aortic aneurysmal leakage and ruptured abdominal aortic aneurysm.

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

Acute aortic syndrome is a difficult-to-diagnose aortic emergency. We propose recommendations to aid clinicians in riskstratifying patients and, depending on risk level, suggest further investigations needed. This guideline is intended as a resource for practising clinicians, both as an evidence base and a guide to investigation for this high-risk aortic catastrophe.

Diagnosis and management of acute aortic syndromes in the emergency department

Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management

Acute aortic syndromes (AAS), including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer, have many different presentations and an extensive differential, including chest pain, back pain, abdominal pain, and syncope.

Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis

ED clinicians may miss AAS by not considering it as a possibility, being falsely reassured by atypical or resolved symptoms, or mistaking it for other more common conditions. Further prospective work is necessary to establish the role of diagnostic aids and biomarkers in UK EDs.