Acute aortic syndrome

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Acute aortic syndrome Microchapters

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Patient Information

Overview

Classification

Aortic dissection
Aortic intramural hematoma
Penetrating atherosclerotic aortic ulcer

Differentiating Acute Aortic Syndrome from other Diseases

Causes

Guidelines

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]

Overview

Acute aortic syndrome (AAS) describes a constellation of emergency conditions with a similar clinical feature that involves the aorta. These include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer. It is possible for AAS to lead to acute coronary syndrome. The term was introduced in 2001.

Classification

Acute aortic syndromes is classified into 5 entities as follows:[1][2]

  • Type I: classic aortic dissection involving an intimal layer between the true and false lumen (with no communication between the two lumen)
  • Type II: aortic dissection with medial rupture and the subsequent intramural hematoma formation
  • Type III: subtle aortic dissection with bulging of the aortic wall
  • Type IV: aortic dissection due to plaque rupture and subsequent ulceration
  • Type V: iatrogenic/traumatic dissection

Differentiating Acute Aortic Syndrome from other Diseases

Causes

Guidelines

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)[5]

Recomendacations Class Level References
History and clinical assessment
In all patients with suspected

AAS, pre-test probability

assessment is recommended,

according to the patient’s

condition, symptoms, and

clinical features.

I B [6]
Laboratory testing
In case of suspicion of AAS,

the interpretation of

biomarkers should always be

considered along with the pretest

clinical probability.

IIa B
In case of low clinical

probability of AAS, negative D-dimer

levels should be

considered as ruling out the

diagnosis.

IIa C [7][8][9][10]
In case of intermediate clinical

probability of AAS with a

positive (point-of-care) D-dimer

test, further imaging

tests should be considered.

IIa B [7][8]
In patients with high probability

(risk score 2 or 3) of AD,

testing of D-dimers is not

recommended.

III C
Imaging
TTE is recommended as an

initial imaging investigation.

I C
In unstabled patients with a

suspicion of AAS, the following

imaging modalities are

recommended according to

local availability and expertise:

TOE I C
CT I C
In stable patients with a

suspicion of AAS, the

following imaging modalities

are recommended (or should

be considered) according to

local availability and expertise:

CT I C
MRI I C
TOE IIa C
In case of initially negative

imaging with the persistence of

suspicion of AAS, repetitive

imaging (CT or MRI) is

recommended.

I C
Chest X-ray maybe

considered in cases of low

clinical probability of AAS.

IIb C
In case of uncomplicated

Type B AD treated medically,

repeated imaging (CT or

MRI)e during the first days is

recommended.

I C

References

  1. Erbel, R (2001). "Diagnosis and management of aortic dissection Task Force on Aortic Dissection, European Society of Cardiology". European Heart Journal. 22 (18): 1642–1681. doi:10.1053/euhj.2001.2782. ISSN 0195-668X.
  2. "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases". European Heart Journal. 35 (41): 2873–2926. 2014. doi:10.1093/eurheartj/ehu281. ISSN 0195-668X.
  3. Smith AD, Schoenhagen P (January 2008). "CT imaging for acute aortic syndrome". Cleve Clin J Med. 75 (1): 7–9, 12, 15–7 passim. doi:10.3949/ccjm.75.1.7. PMID 18236724.
  4. Evangelista Masip A (April 2007). "[Progress in the acute aortic syndrome]". Rev Esp Cardiol (in Spanish; Castilian). 60 (4): 428–39. doi:10.1157/13101646. PMID 17521551.
  5. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
  6. Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.
  7. 7.0 7.1 Eggebrecht, Holger; Mehta, Rajendra H.; Metozounve, Huguette; Huptas, Sebastian; Herold, Ulf; Jakob, Heinz G.; Erbel, Raimund (2008). "Clinical Implications of Systemic Inflammatory Response Syndrome Following Thoracic Aortic Stent-Graft Placement". Journal of Endovascular Therapy. 15 (2): 135–143. doi:10.1583/07-2284.1. ISSN 1526-6028.
  8. 8.0 8.1 Sutherland, Alexander; Escano, Jude; Coon, Troy P. (2008). "D-dimer as the Sole Screening Test for Acute Aortic Dissection: A Review of the Literature". Annals of Emergency Medicine. 52 (4): 339–343. doi:10.1016/j.annemergmed.2007.12.026. ISSN 0196-0644.
  9. Suzuki, Toru; Bossone, Eduardo; Sawaki, Daigo; Jánosi, Rolf Alexander; Erbel, Raimund; Eagle, Kim; Nagai, Ryozo (2013). "Biomarkers of aortic diseases". American Heart Journal. 165 (1): 15–25. doi:10.1016/j.ahj.2012.10.006. ISSN 0002-8703.
  10. Taylor, R. Andrew; Iyer, Neel S. (2013). "A decision analysis to determine a testing threshold for computed tomographic angiography and d-dimer in the evaluation of aortic dissection". The American Journal of Emergency Medicine. 31 (7): 1047–1055. doi:10.1016/j.ajem.2013.03.039. ISSN 0735-6757.


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