Aortic dissection

Last reviewed: 7 Sep 2022
Last updated: 06 Jul 2022

Summary

Definition

History and exam

Key diagnostic factors

  • acute severe chest pain
  • interscapular and lower pain
  • left/right blood pressure differential
  • pulse deficit
  • diastolic murmur
  • features of Marfan syndrome
  • features of Ehlers-Danlos syndrome
  • syncope
  • hypotension
Full details

Other diagnostic factors

  • hypertension
  • dyspnoea
  • altered mental status
  • paraplegia
  • hemiparesis/paraesthesia
  • abdominal pain
  • limb pain/pallor
  • left-sided decreased breath sounds/dullness
Full details

Risk factors

  • atherosclerotic aneurysmal disease
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • bicuspid aortic valve
  • annulo-aortic ectasia
  • coarctation
  • smoking
  • family history of aortic aneurysm or dissection
  • hypertension
  • older age
  • giant cell arteritis
  • overlap connective-tissue disorders
  • surgical/catheter manipulation
  • cocaine/amphetamine use
  • heavy lifting
  • pregnancy
  • non-diabetic
Full details

Diagnostic investigations

1st investigations to order

  • ECG
  • echocardiography
  • chest x-ray
  • CT (chest, abdomen, and pelvis)
  • high-sensitivity troponin
  • renal function tests
  • liver function tests
  • lactate
  • full blood count
  • C-reactive protein
  • group and save/cross match
  • blood gas
  • creatine kinase
  • procalcitonin
Full details

Investigations to consider

  • D-dimer
  • magnetic resonance angiography
  • intravascular ultrasound
Full details

Treatment algorithm

INITIAL

suspected aortic dissection: haemodynamically unstable

ACUTE

confirmed type A aortic dissection

confirmed type B aortic dissection: complicated

confirmed type B aortic dissection: uncomplicated

ONGOING

chronic aortic dissection

Contributors

Expert advisers

Ian Chetter, MBChb, FRCS (eng), MD, FRCS (Gen surg), PGCert Medical Ultrasound, PGDip Clinical Education

Chair of Surgery

University of Hull

Honorary Consultant Vascular Surgeon

Hull University Teaching Hospitals NHS Trust

Hull

UK

Disclosures

IC is Editor in cheif for the Journal of Vascular Societies Great Britain and Ireland, and the research chair for the Vascular Society of Great Britain and Ireland. IC is also a member of NIHR Prioritising Committee, and has recieved research grants from the NIHR.

Alexander Alexiou, MBBS, BSc, DCH, FRCEM, Dip IMC, RCSEd

Emergency Medicine Consultant

Barts Health NHS Trust

Physician Response Unit Consultant

London’s Air Ambulance

Royal London Hospital

London

UK

Disclosures

AA declares that he has no competing interests.

Acknowledgements,

BMJ Best Practice would like to gratefully acknowledge the previous expert contributors, whose work has been retained in parts of the content:

Caitlin W. Hicks MD, MS

Assistant Professor of Surgery

Division of Vascular Surgery and Endovascular Therapy

The Johns Hopkins University School of Medicine

Baltimore

MD

James H. Black III MD, FACS

Chief Vascular Surgery and Endovascular Therapy

Department of Surgery

The Johns Hopkins University School of Medicine

Baltimore

MD

Disclosures

CWH declares that she has no competing interests. JHB is a proctor for Cook, Inc.

Peer reviewers

Greg McMahon, MD, FRCS

Consultant Vascular Surgeon

University Hospitals of Leicester NHS Trust

Honorary Lecturer, College of Life Sciences

University of Leicester

Leicester

UK

Disclosures

GM declares that he has no competing interests.

Editors

Annabel Sidwell,

Section Editor and Comorbidities Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Rachel Wheeler,

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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