Doubt Aortic Dissection?

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    Doubt Aortic Dissection?

    Don’t want to read more? Here is the summary: There are a bunch of studies coming out looking at risk stratification for Aortic Dissection (AD). On chest pain patients check for focal sensory/motor neurologic deficit, pulse deficit and hypotension and look for widening of the mediastinum on CXR. Aortic dissection detection score + d-dimer can help you risk stratify. Von Kodolitsch Score is another option.

    What are the five dangerous causes of chest pain? ACS, PTX, PNA, PE and Dissection. We basically always work up the first 3 with an EKG and CXR. Then we make a decision about whether or not to work up PE using PERC or Wells. And, most of the time we say, “I don’t think this is aortic dissection” and do not work it up further. Is there evidence behind this practice?

    What are the clinical signs of aortic dissection?

    1. Focal neurologic (sensory or motor) deficit
    2. Pulse deficit
    3. Hypotension

    What signs increase the likelihood of aortic dissection?

    • Widened mediastinum on CXR

     

    What risk stratification tools are out there?

    1. American Heart Association Aortic Dissection Detection Score

    *negative LR 0.2, however, should not be used alone because 6% witth score 0 had AD

    If any positive in any column, assign 1 point. Add up points in each column for score of 0, 1, 2, or 3.

    *combined with d-dimer 0.3% (95% CI 0.1% to 1%)

     

    1. Von Kodolitsch Score
      1. Aortic pain (ie, immediate-onset, tearing, or ripping pain)
      2. Mediastinal widening on chest radiograph
      3. Pulse or blood pressure differential

    *Useful to rule out aortic dissection if all 3 are negative (negative LR 0.07)

    *Useful to raise concern for AD if all 3 are positive (positive LR 65.79)

     

    References:

    Ohle R, Kareemi HK, Wells G, et al. Clinical examination for acute aortic dissection: a systematic review and meta-analysis. Acad Emerg Med. 2018;25:397-412.

    Chien N, et al. What Signs Increase the Likelihood of Acute Aortic Dissection? Ann Emerg Med. 2018. 

    Nazerian P, et al.  Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018

    Rogers A, et al. Sensitivity of the Aortic Dissection Detection Risk Score, a Novel Guideline-Based Tool for Identification of Acute Aortic Dissection at Initial Presentation: Results From the International Registry of Acute Aortic Dissection. Circulation. 2011. 

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