Aortic Dissection in the ED: On a Tear… Literally

-Case-
A 62-year-old male with a history of uncontrolled HTN presents with sudden-onset, tearing chest pain radiating to his back. He’s diaphoretic, tachycardic, and his right arm systolic BP is 40 points lower than the left. CXR shows a widened mediastinum. 

-Evaluation-
Aortic dissection is a life-threatening condition where a tear in the intimal layer of the aorta allows blood to track between the layers of the vessel wall. It’s most common in older adults with hypertension, but younger patients with connective tissue disorders (like Marfan’s) are also at risk.

Symptoms:

  • Sudden, severe chest or back pain (often described as tearing or ripping)
  • Neurologic symptoms (stroke-like findings, syncope)
  • Pulse deficits or unequal BPs in extremities
  • Hoarseness, dyspnea, or shock if complications occur

Risk Factors:

  • Chronic HTN
  • Connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos)
  • Bicuspid aortic valve
  • Cocaine use
  • Recent aortic manipulation/surgery

Types (Stanford Classification):

  • Type A: Involves the ascending aorta (surgical emergency)
  • Type B: Involves the descending aorta only (medical management unless complicated)

Diagnosis in the ED:

  • CT angiography is the gold standard for stable patients (TEE if unstable or CTA not feasible)
  • CXR may show widened mediastinum, abnormal aortic contour, or pleural effusion
  • ECG and troponins to rule out MI (dissection can mimic ACS!)

-Management-

  • Control BP and heart rate to reduce shearing force: target SBP 100-120 mmHg, HR <60 bpm
    • First-line agents: IV beta blockers (go for your faster acting ones first! e.g., esmolol, labetalol)
    • Add vasodilators (e.g., nicardipine) if SBP still elevated despite BB’s
  • Type A dissections: immediate cardiothoracic surgical consult
  • Type B dissections: medical management unless presenting with complications (e.g., organ ischemia, rupture)

-Fast Facts-

  • Time is a killer: mortality increases by 1% per hour if untreated
  • Pain may migrate as the dissection progresses
  • A normal CXR does not rule out dissection
  • Don’t give anticoagulants until dissection is ruled out

When a patient tells you it feels like their chest is tearing apart, take it seriously. Aortic dissection might not be common, but it’s deadly if missed. Your job: catch it fast, control the pressure, and call the surgeon.

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Cheers,

Tamir Zitelny, MD

-References-

  1. Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015;385(9970):800-811. doi:10.1016/S0140-6736(14)61005-9
  2. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 2010;121(13):e266-e369. doi:10.1161/CIR.0b013e3181d4739e
  3. Bossone E, Evangelista A, Isselbacher EM, et al. Prognostic role of transesophageal echocardiography in acute type A aortic dissection. Am Heart J. 2007;153(6):1013-1020. doi:10.1016/j.ahj.2007.03.027
  4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903. doi:10.1001/jama.283.7.897
  5. Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010;140(4):784-789. doi:10.1016/j.jtcvs.2010.01.027

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