Updated: 2/17/2019

Aortic Dissection

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Snapshot
  • A 32-year-old man with eunuchoid proportions and arachnodactyly presents to the emergency department with severe substernal chest pain that radiates to the back. He says that the pain occurred acutely and denies any recent trauma. Medical history is significant for Marfan syndrome. On physical exam, there are unequal blood pressures in the upper extremity. A chest radiograph demonstrates a widened mediastinum. A CT angiography demonstrates a Stanford A type aortic dissection.
Introduction
  • Clinical definition
    • a separation of the media laminal planes, resulting in a blood-filled space in the aortic wall 
      • there are two types of aortic dissection
        • Stanford A type
          • a dissection involving the ascending aorta 
        • Stanford B type
          • a dissection involving only the descending aorta
  • Etiology
    • hypertension (most common)
    • connective tissue disease
    • iatrogenic (e.g., coronary catheterization)
    • trauma 
  • Pathogenesis
    • an intimal tear of the aorta causes an intramural aortic hemorrhage that separates the intima from the media
      • the resulting hematoma may rupture through the adventitia, leading to a thoracic or abdominal cavity hemorrhage or cardiac tamponade
  • Associated conditions
    • Marfan syndrome 
    • bicuspid aortic valve
      • e.g., Turner syndrome
  • Prognosis
    • Stanford type A
      • effective blood pressure control and surgical treatment improves mortality
    • Stanford type B
      • effective conservative or surgical treatment improves mortality
Presentation
  • Symptoms
    • acute chest or back pain (most common) 
      • classically anterior chest pain that radiates to the back between the scapulae
  • Physical exam
    • unequal blood pressures in the arms
    • weak or absent pulses
    • diastolic decrescendo murmur when the aortic valve is involved
      • resulting in aortic regurgitation
Imaging
  • Radiography of the chest
    • indication
      • to rule out other causes of chest pain (e.g., pneumothorax)
    • finding
      • widened mediastinum
  • CT angiography of the chest  
    • indication
      • most accurate imaging test for aortic dissection 
  • Transesophageal echocardiography 
    • can be used if kidney injury is present or patient is allergic to contrast
Differential
  • Myocardial infarction 
    • differentiating factors
      • an electrocardiogram may be present (e.g., ST-segment elevation)
      • increased cardiac biomarkers
Treatment
  • Medical 
    • β-blockers 
      • indication
        • Stanford type B aortic dissection
  • Surgical
    • vascular surgery
      • indication
        • Stanford type A aortic dissection
Complications
  • End-organ damage
    • secondary to poor perfusion
  • Aneurysm rupture
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.4692) A 62-year-old male with hypertension, diabetes, and coronary artery disease presents with sudden onset chest pain for the past two hours. The patient describes the pain as a tearing sensation in the center of his chest without any radiation. The patient endorses feeling nauseous and sweaty. The patient’s vitals signs are as follows: temperature is 98.7 deg F (37.1 deg C), blood pressure is 173/68 mmHg, pulse is 92/min, respirations are 14/min. An electrocardiogram demonstrates left axis deviation but no ST segment changes, Q waves, left bundle branch morphology, or T wave inversions are seen. The patient’s troponin level is 0.05 ng/mL. A chest radiograph demonstrates the following findings (Figure A). Which of the following is the most appropriate next diagnostic step? Review Topic

QID: 107672
FIGURES:
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1

Esophagogastroduodenscopy

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Transthoracic echocardiogram

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Left heart catheterization and angiogram

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Thoracic and abdomen CT angiogram

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Thoracic and lumbar spine radiograph

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