see also: [[tamponade]] > case: [Bloating = type B dissection](https://www.medscape.com/viewarticle/bloating-or-aortic-tear-68-year-olds-shocking-diagnosis-2025a1000iic) > [!Key Points] > - severe chest pain with normal ECG, consider dissection > - **Chest pain PLUS...** > - Atypical presentations account for up to 25% of acute aortic syndrome cases, and correlate with missed diagnosis. ACS most commonly misdiagnosed, and aortic dissection presenting with ECG changes correlates with missdiagnosis (PE is less common misdiagnosis, although question this PDx if the pain onset is sudden and pt has risk factors for dissection) > - lower HR first, then lower BP (or just use labetalol) - Ascending (+/- descending also): type A -- surgery - Descending only (distal to origin of left subclavian): type B -- often medical > [!tldr] research highlights > - [DAShED BMJ 2023](https://www.stemlynsblog.org/the-dashed-study/) > - Rare condition (3% of CTs positive) and decision tools are bad > - [needle in haystack commentary](https://emj.bmj.com/content/41/3/134) > - [The risk of misdiagnosis in acute thoracic aortic dissection: a review of current guidelines (2020).](bookends://sonnysoftware.com/ref/DL/249052) > - [A missed diagnosis of acute aortic syndrome is associated with ischaemic ECG changes and an initial suspicion of myocardial infarction: a retrospective observational study (2025)](https://link.springer.com/article/10.1186/s12873-025-01404-8) - [bookends](bookends://sonnysoftware.com/ref/DL/260559) # Risk factors - HTN - atherosclerosis - coarctation of aorta (younger patients) - peek incidence age 40-70 - Connective tissue disease - Marfan's - less common: ehleros danlos - aortic valve disease (eg bicuspid) - Dilated aorta > 50 mm likely a risk - Prior AV surgery or mitral surgery also likely a risk ; consider if they have had extensive aortic surgery that may dehisce and cause pseudoaneurysm - aortic aneurysm (dilated >1.5x normal size - drugs ([[Cocaine]]) - coronary angiogram - CABG (from cannulation site or clamp) # life threatening complications 1. cardiac tamponade (most common) 2. Acute aortic incompetence (aortic regurgitation, aortic insufficiency, or a leaky aortic valve) 3. dissection **into coronary artery** (often *RCA*) --> inferior MI 4. stroke # Signs and symptoms - acute onset tearing/ripping pain (can be like the SAH of chest pain!) - usually present hypertensive (ominous if hypotensive) - rarely Beck's triad (hypotension, elevated JVP, quiet heart sounds) - ECG can be normal or show features of acute ischemia - Other changes may show [[STEMI ECG patterns#Inferior MI]] or [[STEMI mimics|LVH]] changes - pulse deficits (if disceting up into another vessel in aortic arch ![[Pasted image 20230519165354.png]] Type A dissection # Treatment - reduce rate (reduce sheering stress) and THEN lower BP - ?labetalol for both **Aim HR 60** - metoprolol 1-2.5mg IV boluses repeat Q3-5 min - [[labetalol]] 5-20mg IV boluses Q5-10 minutes - infusion 20-160mg/hour (0.5-2mg/min) - esmolol 500 mcg/kg over 1 min loading dose - slow IV 50 mcg/kg/min over next 4 min - infusion 50-200 mcg/kg/min - propranolol - 1-3mg IV Q5min Calcium channel blockers (dilt and verapamil) 2nd line if cannot give beta blockers **Aim systolic BP 100-110mmHg** - labetalol - GTN infusion 5-50mcg/min - increase by 3-5 mcg/min Q 3-5 min as required - Sodium Nitroprusside (comes in 50mg ampoules) - 0.25 mcg/kg/min initial rate - titrate to response every 2-3 min up to 10 mcg/kg/min - **>2.5 mcg/kig/min** for >4 hours can cause cyanide toxicity - hydralazine -- longest acting so least preferred - 5-10mg IV over 5-10 min - repeat every 15-20 min PRN # Aortic dissection risk score - any high risk condition (marfan syndrome, family history, known aortic valve disease, recent surgery, known aneurysm, [[Pregnancy physiological changes |pregnancy]]) - any high risk pain feature (chest, back, or abdominal pain described as abrupt onset, severe intensity, or ripping/tearing) - any high risk exam feature (evidence of perfusion defect eg pulse defect or systolic BP differential, focal neuro deficit, new aortic insufficiency murmur, hypotension/shock score 0-1 - D dimer cutoff <0.5 score >1 - consider going great to CTA # Related Questions ## aortic dissection - [x] 1Q: [Aortic dissection](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=2) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=1) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=2) - [x] 2Q: [Chest and interscapular pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=14) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=12) - [ ] 3Q: [Aortic Dissection](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=64) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=24) - [ ] 4Q: [Aortic Dissection](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=59) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=25) - [ ] 5Q: [Aortic Dissection](x-devonthink-item://D466AD93-18B7-467C-BB6E-192EEBE26935?page=11) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=4) - [ ] 6Q: [If Time is Money This Guy is Broke](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=48) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=30) - [ ] 7Q: [Chest Pain](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=13) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=9) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=4) ## chest pain - [ ] 8Q: [Aortic dissection](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=7) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=10) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=11) - [ ] 9Q: [Chest pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=21) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=21) - [ ] 10Q: [Pericardial Effusion](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=57) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=37) - [ ] 11Q: [Pericardial Effusion](x-devonthink-item://F0CF1E99-6E8D-4E3C-9C45-046E93F30DBA?page=17) -- [Answer](x-devonthink-item://E437B768-E942-4349-941C-A97410E4E28F?page=12) ## dissection - [x] DUPLICATE Q: [Aortic dissection](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=7) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=10) ## tamponade - [ ] 95Q: [Pericardial tamponade](x-devonthink-item://71171BE8-7F92-40FA-99D2-0FF4C482F766?page=4) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=17) - [x] DUPLICATE Q: [Pericardial Effusion](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=57) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=37)