Acute Aortic Syndromes: Diagnosis and Management

Bossone E, LaBounty TM, Eagle KA.
Acute Aortic Syndromes: Diagnosis and Management, an Update. Eur Heart J 2017;Jun 30:[Epub ahead of print].

The following are key points to remember about this update on the diagnosis and management of acute aortic syndromes (AAS):

  1. AAS encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural hematoma, and penetrating atherosclerotic aortic ulcer.
  2. AAS may be associated with nonspecific symptoms and physical signs, and a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur.
  3. To reduce the diagnostic time delay, a comprehensive flow chart for decision making based on pretest sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases, and thus, should be applied in the emergency scenario.
  4. In the emergency scenario, a rapid comprehensive diagnostic workup is mandatory, including clinical assessment (pretest probability of disease), laboratory data (mainly D-dimer and troponin), chest X-ray, and electrocardiography, in order to expedite aortic imaging (transthoracic echocardiography + computed tomography and/or transesophageal echocardiography) in the appropriate subset of these patients.
  5. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken by a highly specialized multidisciplinary aortic team.
  6. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended.
  7. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) may be indicated.
  8. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts.
  9. There is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programs, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
  10. Finally, patient education about this condition and smoking cessation and risk factor modification for atherosclerotic disease need to be reinforced in all patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Interventions and Vascular Medicine, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Aortic Diseases, Aorta, Thoracic, Cardiac Imaging Techniques, Cardiac Surgical Procedures, Dissection, Echocardiography, Transesophageal, Echocardiography, Electrocardiography, Endovascular Procedures, Hematoma, Risk Factors, Secondary Prevention, Smoking Cessation, Tomography, X-Ray Computed, Troponin, X-Rays

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