Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastro- oesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion Tamponade |Pneumothorax |Tension Pneumothorax |Shingles | Ankle-Brachial pressure Index (ABPI) and Peripheral Vascular Disease | Peripheral Arterial Disease (PAD) | Abdominal Aortic Aneurysm (AAA) | Carotid Endarterectomy | Buerger's disease (Thromboangiitis obliterans ) | Leriche syndrome (aortoiliac occlusive disease)

🚨 The most critical step is to consider aortic dissection in any patient with chest pain — misdiagnosis as MI ❤️‍🔥 or PE 🩸 is dangerous, since anticoagulation increases the risk of fatal bleeding. Early recognition + urgent referral are lifesaving.

🤰 Consider dissection in pregnancy and postpartum chest pain (with PE). 🖥️ POCUS can be lifesaving at bedside.

📖 About Aortic Dissection

• Mortality: ~40% die at onset ⚰️; another 10% peri/post-op.
• Urgent CT Aortogram essential 🖥️.
• Type A = surgery; Type B = medical management.
• Beta-blockade crucial to reduce shear stress 💊.
• Chronic dissection (rare) → ongoing pain, HF signs.

🧬 Aetiology

👶 Young patients: connective tissue disorders (e.g. Marfan, Ehlers–Danlos). 👴 Older patients: hypertension, atherosclerosis.

• Aortic wall layers: intima, media, adventitia.
• Tear in intima → blood into media → false lumen forms.
• Extensions: ➡️ Antegrade → distal vessels 🫀 ⬅️ Retrograde → valve, coronaries, tamponade 💧 💥 Rupture → haemothorax, sudden death 🔁 Re-entry → stabilisation possible

🗂️ Classification

• Stanford: • Type A = ascending aorta (2/3 cases) ⚡ → surgery • Type B = descending aorta → medical
• DeBakey: • I = Ascending + arch/descending • II = Ascending only • III = Descending only

⚠️ Risk Factors

• ♂ > ♀, >60 yrs
• Hypertension, atherosclerosis
• Connective tissue disorders 🧬
• Trauma, bicuspid AV, prior surgery
• Cocaine use 💊, pregnancy 🤰
• Aortitis (Takayasu, GCA) 🧪

🩺 Clinical Presentation

• Sudden tearing chest pain radiating to back ⚡🖤
• Shock or hypertension, different BP between arms 💪
• Aortic regurg murmur + pulmonary oedema 🌊
• Syncope (~15%) due to tamponade/major vessel occlusion

❗ Complications

• Type A: Tamponade 💧, rupture 💥, AR → HF, stroke 🧠
• Type B: Spinal stroke 🦽, mesenteric/renal ischaemia ⚠️, haemothorax 🫁

🔎 Investigations

• Bloods: U&E, FBC, group & crossmatch 💉
• CXR: widened mediastinum 📏, left pleural effusion
• ECG: may mimic MI (if RCA involved) ❤️‍🔥
• D-dimer: often ↑, normal helps exclude ❌
• CT Aortogram = gold standard 🖥️
• TOE: rapid diagnosis if unstable

🛠️ Management

• ABC + monitoring ⚡
• Pain: IV morphine 💊
• Lower BP: IV labetalol (± nitroprusside) ⬇️
• Type A = 🚑 surgery (mortality rises 1–2% per hr delay!)
• Type B = strict BP control + endovascular stent (TEVAR) where indicated

📚 References

• 2014 ESC Aortic Disease Guidelines

🧑‍⚕️ Case Examples — Aortic Dissection

• Case 1 (Type A — ascending aorta): 💔 A 58-year-old man with poorly controlled hypertension presents with sudden severe “tearing” chest pain radiating to the back. He is diaphoretic, with unequal arm BPs. ECG is non-diagnostic, troponin normal. Analysis: Classic Type A dissection involving the ascending aorta — high mortality if untreated. Diagnosis: CT angiography confirms Stanford Type A dissection. Management: Immediate BP control with IV labetalol, urgent cardiothoracic surgical repair.
• Case 2 (Type B — descending aorta): 🫀 A 70-year-old woman with long-standing hypertension and COPD develops sudden tearing interscapular back pain. BP is 210/110, both arms equal. No signs of end-organ malperfusion. Analysis: Stanford Type B dissection (distal to left subclavian artery). Often managed medically if uncomplicated. Diagnosis: CT angiogram shows descending thoracic aortic dissection. Management: Aggressive BP control (IV beta-blocker, vasodilator), pain relief, monitoring. Surgery/endovascular stent reserved for complications (rupture, malperfusion, uncontrolled pain/HTN).
• Case 3 (Complicated dissection with malperfusion): 🚨 A 65-year-old man with Marfan’s syndrome presents with severe chest pain, syncope, and left leg weakness. On exam: BP 90/60, reduced left femoral pulse, new diastolic murmur. Analysis: Aortic dissection complicated by branch vessel involvement (left iliac, aortic regurgitation, possible tamponade). Diagnosis: Stanford Type A dissection with end-organ compromise. Management: Resuscitation, IV beta-blockade, urgent surgical repair. Prognosis poor without immediate intervention.