Acute aortic dissection and other disease of aorta

Question 1

clinical presentation of acute aortic dissection predisposing factors? HPI? PE?

Answer 1

history of HTN,

marfan’s,

cocaine use.

presents with severe sharp tearing chest pain or back pain

>20 mm Hg variation in SBP between arms.

Question 2

Complications of acute aortic dissection due to extension

Answer 2

stroke (carotid artery)

acute aortic regurgitation (aortic root or valve)

horner’s syndrome (carotid sympathetic plexus)

myocardial ischemia/infarction (coronary artery ostia)

pericardial effusion/tamponade (pericardium)

hemothorax (pleural cavity)

renal injury (renal arteries)

abdominal pain (mesenteric arteries)

lower extremity paraplegia (spinal arteries)

Question 3

what is an atypical presentation and cause of chest pain in pregnancy especially if patient has HTN, horner’s syndrome?

Answer 3

aortic dissection which can occur spontaneously of aorta or coronary arteries Seen commonly in third trimester due to hyperdynamic state and hormonal effect of vasculature.

Question 4

Why do we see Horner’s syndrome with acute aortic dissection?

Answer 4

anisocoria, ptosis are due to the dissection extending to into the carotid artery externally compression the left superior cervical sympathetic ganglion.

Question 5

stabbing chest pain and vocal cord paralysis

Answer 5

dissection with compression of left recurrent laryngeal nerve. Pulse deficits are classic but also absent in 30% of pts and atypical in women

Question 6

Best imaging study to evaluate for aortic dissection

Answer 6

CT angiography - test of choice if pregnant should be avoided in pregnancy, Can get TTE by cardiologist in ED and avoids radiation exposure. Less sensitive as it fails to assess large portions of aorta especially in pregnant women MR angiography is slower but avoids radiation and doesn’t need iodinated contrast

Question 7

what to do after strongly suspecting acute aortic dissection?

Answer 7

Depends on if ascending vs descending. ascending confirmed via bedside TTE to avoid delay in definitive surgical management and do TTE than TEE. Also need to go OR and not percardiocentesis because out comes are better with acute surgery. descending - BP control with IV beta blocker

Question 8

Risk factors for abdominal aortic aneurysm are:

Answer 8

age>60 years, male gender, cigarette smoking, white race, atherosclerosis and family history of AAA.

Question 9

major risk factors associated with aneurysmal expansion of aorta and rupture include:

Answer 9

diameter >5.5cm expansion rate >0.5 cm every 6 months or >1 cm per year active cigarette smoking.

Question 10

what modifiable risk factor causes the highest risk for aneurysmal rupture?

Answer 10

active smoking unclear but suspect related to connective tissue degeneration in the aortic wall.

Question 11

EKG findings on acute aortic dissection

Answer 11

EKG can be normal or nonspecific ST or T wave changes CXR mediastinal widening CT angiography or TTE for definitive diagnosis

Question 12

Treatment of aortic dissection

Answer 12

morphine pain control IV beta blockers (esmolol or labetalol) to get HR<60 and SBP<120 within 30 minutes If not enough BP control, then sodium nitroprusside if SBP>120 mmHg Emergent surgical repair for ascending dissection

Question 13

what meds that can worsen aortic dissection

Answer 13

antiplatelets - do not do this if concerned about dissection due to the sharp character of pt’s chest pain is atypical in cardiac chest pain and no definite ischemia on EKG.

Question 14

anterior chest pain and neck pain and widened mediastinum

Answer 14

acute aortic dissection of ascending aorta neck = suggests coronary artery ischemia by occlusion of dissecting flap can see T wave inversions on EKG

Question 15

chest pain and back pain and widened mediastinum

Answer 15

may be suggestive of descending aortic dissection - present with back pain as opposed to neck pain

Question 16

what is this?

Answer 16

Question 17

When to screen pts who have Marfan’s dx for aortic dissection?

Answer 17

TTE at diagnosis and at regular intervals with close monitoring of the aortic root and ascending aorta

Operative treatment is needed in aortic root diameter >50 mm to reduce risk for rupture or dissection.

Question 18

what non cardiac conditions can cause aortic dilation over time?

Answer 18

cardiac syphilis

Marfan’s - not Ehler’s Danlos.

autosomal polycystic kidney disease

Chagas

Question 19

When to screen for aortic dilation and dissection in Marfan pts?

Answer 19

TTE at diagnosis

and at regular intervals with close monitoring of the aortic root and ascending aorta

Operative treatment is needed in aortic root diameter >50 mm to reduce risk for rupture or dissection.

Aortic dissection is a major cause of death in Marfan pts, up to 40%

Question 20

Beck’s triad is

Answer 20

distended neck veins

muffled heart sounds

hypotension

concern for possible cardiac tamponade (obstructive shock).

may see low QRS voltage and electrical alternans