Diagnosis and management of acute aortic syndromes in the emergency department

Abstract

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta.AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). 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.

Th1, Th2, and Th17 cells are dysregulated, but only Th17 cells relate to C‐reactive protein, D‐dimer, and mortality risk in Stanford type A aortic dissection patients

“…CRP and D‐dimer are two well‐established biomarkers in acute Stanford type A AD 22‐24 . Then, the associations of Th1, Th2, and Th17 cells with these two markers were conducted by a series of correlation analyses in the current study.…”

Acute aortic dissection with highly compressed true lumen: unanticipated pitfall of point-of-care ultrasonography

“…Indirect findings include dilation of the aorta (>40 mm), pericardial effusion and cardiac tamponade and AR more than moderate levels. 4 Detection of any POCUS findings suggesting AAD has a sensitivity of 88% (95% CI: 76% to 95%). 5 CTA findings revealed that our patient had a highly compressed true lumen and enlarged false lumen.…”

D-Dimer Tests in the Emergency Department: Current Insights

“…In the original score, the D-dimer was not considered and the level of risk was determined based on anamnestic data and 47 In fact, as well as for PE, patients with organ ischemia or hemodynamic instability require urgent diagnosis and treatment and D-dimer evaluation is not useful in these conditions. 48 In high-risk patients, the D-dimer dosage was negative (<500 ng/mL) in a significant number of cases, leading to a failure rate of 4.4%. On the other hand, in patients with low-intermediate risk (ADD-RS ≤1), who represented the vast majority of screened subjects, the integration of the ADD-RS score with the D-dimer test allowed to exclude AASs with a good accuracy and a failure rate of 0.3%.…”