Nontraumatic thoracic aortic dissection: Difference between revisions
(ascending/descending Ao) |
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| Line 5: | Line 5: | ||
== Risk Factors == | == Risk Factors == | ||
*Preexisting aneurism | |||
*HTN | *HTN | ||
*Inflammatory vasculitis | *Inflammatory vasculitis | ||
| Line 24: | Line 24: | ||
==Clinical Features== | ==Clinical Features== | ||
*Chest Pain - Abrupt, severe (90% of pts) radiating to back | *Ascending Ao | ||
* | **Acute aortic valve regurgitation, leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66% | ||
* | **MI/Ischemia on ECG, usually inferior | ||
**Cardiac Tamponade | |||
**Hemothorax - if adventitia disruption | |||
**Horners, partial - sympathetic ganglion | |||
**Voice hoarseness - recurrent laryngeal n. compression | |||
**CVA/Syncope - if carotid extension | |||
**Neurological deficits | |||
**SBP>20mmhg difference between arms | |||
*Descending Ao | |||
**Chest pain, back pain, abdominal pain | |||
***Chest Pain - Abrupt, severe (90% of pts) radiating to back | |||
**Hypertension | |||
**Hemiplegia, neuropathy (15%) | **Hemiplegia, neuropathy (15%) | ||
**Renal failure | |||
**Distal Pulse deficits/ Limb ischemia | |||
**Mesenteric ischemia | |||
==Diagnosis== | ==Diagnosis== | ||
Revision as of 17:11, 23 January 2013
Background
- Most commonly seen in men 60-80 yrs old
- Intimal tear w/ blood leaking into media
Risk Factors
- Preexisting aneurism
- HTN
- Inflammatory vasculitis
- Smoking
- Cocaine
- 3rd trimester pregnancy
- Decelerating trauma
- Connective tissue disorders (Marfan, Ehlers Danlos syndrome)
- Bicuspid aortic valve
- History of surgery (coarctation of aorta repair, aortic valve replacement, cardiac cath)
Classification (Stanford)
- Type A - Involves any portion of ascending aorta
- Requires surgery
- Type B - Isolated to descending aorta
- Primarily medical management with surgery consultation
Clinical Features
- Ascending Ao
- Acute aortic valve regurgitation, leading to a diastolic decrescendo murmur, hypotension, or heart failure, in 50%-66%
- MI/Ischemia on ECG, usually inferior
- Cardiac Tamponade
- Hemothorax - if adventitia disruption
- Horners, partial - sympathetic ganglion
- Voice hoarseness - recurrent laryngeal n. compression
- CVA/Syncope - if carotid extension
- Neurological deficits
- SBP>20mmhg difference between arms
- Descending Ao
- Chest pain, back pain, abdominal pain
- Chest Pain - Abrupt, severe (90% of pts) radiating to back
- Hypertension
- Hemiplegia, neuropathy (15%)
- Renal failure
- Distal Pulse deficits/ Limb ischemia
- Mesenteric ischemia
- Chest pain, back pain, abdominal pain
Diagnosis
- ECG
- Ischemia (esp inferior) - 15%
- Nonspec ST-T changes - 40%
- CXR
- Abnormal in 90%
- Mediastinal widening (seen in 63%)
- Left sided pleural effusion (seen in 19%)
- Widening of aortic contour, displaced calcification (6mm), aortic kinking, double density sign
- Abnormal in 90%
- CT Aortogram
- Study of choice
Treatment
- Keep SBP 100-120, HR 60-80
- Beta-Blockers
- Esmolol
- Advantage of short half life, easily titratable
- Bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
- Metoprolol
- 5mg IV x 3; infuse at 2-5mg/hr
- Labetalol
- 10-20mg w/ repeat doses of 20-40mg q10min up to 300mg
- Esmolol
- Vasodilators
- Only use if beta-blocker is ineffective
- Do not use without a beta-blocker (must suppress reflex tachycardia)
- Nitroprusside 0.3-0.5mcg/kg/min
Complications
- AV Regurgitation/Insufficiency
- CHF w/ diastolic murmur
- Rupture
- Pericardium: tamponade
- Mediastinum: hemothorax
- Vascular obstruction
- Coronary: ACS
- Carotid: CVA
- Lumbar: Paraplegia
See Also
Source
Tintinalli