Aortic Dissection

Acute aortic syndrome should be considered with abrupt severe chest, back, or abdominal pain, especially with pulse deficit, limb blood-pressure differential, neurologic deficit, new aortic regurgitation murmur, syncope, hypotension, known thoracic aortic disease, recent aortic manipulation, or heritable aortopathy. Measure blood pressure in both arms and lower extremities and assess for coronary, cerebral, visceral, renal, spinal, and limb malperfusion. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

CTA is the recommended initial diagnostic study because it is rapid, widely available, and delineates the dissection extent, entry tear when visible, branch-vessel involvement, malperfusion, hemopericardium, mediastinal hemorrhage, and pleural effusion. For suspected acute aortic syndrome, obtain noncontrast images first when feasible to identify intramural hematoma, followed by arterial-phase CTA from the thoracic inlet through the femoral arteries. ECG-gated acquisition improves assessment of the root and ascending aorta. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

TEE is a useful bedside alternative in unstable patients or when iodinated contrast is unsuitable; it also defines aortic regurgitation, pericardial effusion, and true-versus-false lumen flow. MRI is highly accurate but is generally reserved for stable patients when CT is contraindicated or uncertainty persists because acquisition and monitoring are less practical in unstable patients. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Stanford type A includes any dissection involving the ascending aorta; type B spares the ascending aorta. The current SVS/STS temporal classification defines hyperacute disease as <24 hours, acute as 1 to 14 days, subacute as 15 to 90 days, and chronic as >90 days after symptom onset. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

All acute aortic syndromes require prompt ICU care with invasive arterial pressure monitoring and anti-impulse therapy. Begin an IV beta blocker unless contraindicated; the guideline identifies esmolol, metoprolol, and labetalol as commonly used agents. If beta blockade is contraindicated or not tolerated, IV verapamil or diltiazem is a reasonable alternative for heart-rate control. The supplied sources support targets but do not provide regimen-specific dosing; use institutional protocols and product labeling. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

After heart-rate control, add an IV vasodilator if blood pressure remains above goal; commonly used agents include nicardipine, clevidipine, and sodium nitroprusside. Avoid initiating a vasodilator before rate control because reflex tachycardia can increase aortic wall stress. Treat pain, generally with IV opioids, because pain-driven sympathetic activation impairs hemodynamic control. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Acute type A dissection requires emergency surgical consultation and immediate operative intervention because medical management alone carries substantially higher mortality. In IRAD, medical mortality was 57% compared with 18% surgical mortality in contemporary cohorts; untreated symptomatic ascending dissection has early mortality of approximately 1% to 2% per hour after symptom onset. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

If the patient is stable enough for transfer, management at a high-volume aortic center is reasonable. High-volume multidisciplinary teams have lower mortality, and guideline-supported aortic centers integrate cardiac surgery, vascular/endovascular expertise, advanced imaging, anesthesiology, and critical care. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Neurologic injury alone should not reflexively preclude surgery. In patients with nonhemorrhagic stroke complicating type A dissection, surgery is reasonable over medical therapy; reported mortality with surgical versus medical treatment was approximately 25% to 27% versus 76%. Complete internal carotid occlusion with cerebral edema risk is a particularly poor-prognosis subgroup requiring individualized multidisciplinary assessment. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Initial management of uncomplicated acute type B dissection is medical anti-impulse therapy. This remains the guideline-recommended strategy despite substantial late risk of aneurysmal degeneration, because prophylactic TEVAR has remodeling benefits but uncertain universal early clinical benefit. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Complicated acute type B dissection requires urgent intervention. Complications include rupture, branch-vessel occlusion or malperfusion, dissection extension, progressive enlargement, intractable pain, and uncontrolled hypertension. With suitable anatomy, TEVAR is recommended for rupture and is reasonable over open repair for other complications. Persistent static malperfusion may require adjunctive fenestration or branch-vessel stenting after TEVAR. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

In selected uncomplicated patients with high-risk imaging features, TEVAR may be considered. These features include maximal aortic diameter >40 mm, false-lumen diameter >20 to 22 mm, entry tear >10 mm, entry tear on the lesser curvature, interval total-aortic-diameter increase >5 mm, bloody pleural effusion, or imaging-only malperfusion. Refractory hypertension despite more than three maximally tolerated antihypertensive classes, persistent pain >12 hours despite maximal therapy, and readmission are additional high-risk clinical features. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Long-term therapy after acute aortic syndrome should include beta blockers unless contraindicated; add ACE inhibitors or ARBs as needed to control blood pressure. Long-term calcium-channel blocker therapy may be best avoided in Marfan syndrome when alternatives can achieve blood-pressure control because adverse signals have been reported in experimental and registry data. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

For dissection or intramural hematoma managed medically or treated with open or endovascular repair with residual disease, perform CT or MRI at 1, 6, and 12 months and then annually if stable. TTE complements cross-sectional imaging by following root anatomy and aortic valve function. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Screen first-degree relatives of patients with aortic root or ascending aortic aneurysm or aortic dissection with aortic imaging. Obtain a multigenerational history of thoracic aortic disease, unexplained sudden death, and peripheral or intracranial aneurysms. Genetic testing is recommended when risk factors for heritable thoracic aortic disease are present, including syndromic features, age <60 years, or relevant family history. jaccjacc2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines