Acute aortic syndrome

From IDWiki

Background

Epidemiology

  • Incidence of about 3 per 100,000 people
  • About 25% go undiagnosed for more than 24 hours after ED presentation

Clinical Presentation

Complications and Prognosis

  • Mortality is proportional to delay in diagnosis, about 2% per hour

Diagnosis

  • Mainly made by ECG-gated contrast-enhanced CT of the aorta
  • Current recommended approach1 is to clinically risk stratify (see Pretest Probability, below)
    • For low risk, no further investigations are needed; for intermediate risk, use D-dimer to exclude AAS; for high risk, or for intermediate risk with elevated D dimer, proceed to ECG-gated CT aorta

Pretest Probability

Feature Criterion Score
Risk factors No risk factors 0
Any nonaneurysmal risk factors, including connective tissue diseases, aortic valve disease, recent aortic manipulation, or family history of AAS 1
Aortic aneurysm 2
High-risk pain features No high-risk pain features 0
1 or 2 high-risk pain features, including severe or worst ever, thunderclap or abrupt, tearing or ripping, or migrating or radiating 1
3 or more of the above high-risk pain features 2
Physical examination findings No high-risk physical exam findings 0
Any high-risk physical examination finding, including pulse deficit, neurologic deficit, aortic insufficiency, or hypotension with SBP <90 or pericardial effusion 2
Alternative diagnosis Suspicion for an alternative diagnosis -1
Unsure 0
AAS is the most likely diagnosis 1
  • Interpretation:
    • 0: low-risk (<0.5%); no further investigations
    • 1: moderate-risk probability (0.5 to 5%): D-dimer to further stratify
    • ≥2: high-risk probability (>5%): ECG-gated CT aorta

References

  1. ^  Robert Ohle, Justin W. Yan, Krishan Yadav, Alexis Cournoyer, David W. Savage, Prasad Jetty, Rony Atoui, Bindu Bittira, Brock Wilson, Ashish Gupta, Niamh Coffey, Yvonne Callaway, Jeffrey Middaugh, Dominique Ansell, Fraser Rubens, Stephen J. Bignucolo, Terena-Marie Scott, Sarah McIsaac, Eddy Lang. Diagnosing acute aortic syndrome: a Canadian clinical practice guideline. Canadian Medical Association Journal. 2020;192(29):E832-E843. doi:10.1503/cmaj.200021.