Acute aortic dissection

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Acute aortic dissection

Acute aortic dissection

Statistics
  • Incidence 3–16/100 000 per year.

  • Men > women 2:1.

  • Peak incidence 6th decade.

  • True incidence may be underestimated because mortality can be attributed to another cardiac condition.

  • In a city or region of the UK with a population of 2 million people, roughly 140 people per year will die from this disease (Br Journal Cardiol 2023;30:16).

    • Acute aortic dissection is one of those conditions you hope never to see in primary care. This article focuses on the emergency presentation of aortic dissection from a primary care perspective, drawing on a Lancet review from 2023 (Lancet 2023;401:773).

    This article was updated in October 2023.

    When to suspect acute aortic dissection

    Aortic dissection is typically seen in males >50y, but can occur in younger patients, particularly those with high-risk predisposing conditions. 

    High-risk presenting symptoms

    Consider aortic dissection in patients presenting with sudden-onset chest or back pain. However, most cases will have high-risk features:

    • Sudden, severe tearing or ripping pain in the chest, back or abdomen.
    • Syncope.
    • Signs of ischaemia (mesenteric, limb or renal ischaemia).

    Predisposing conditions

    These things should make us more concerned:

    • Family history of aortic disease.
    • Known thoracic aortic aneurysm; recent aortic surgery.
    • Medication: quinolones, glucocorticoids, immunosuppressants, cytotoxic medication.
    • Some connective tissue disorders such as Marfan's syndrome, some types of vascular Ehlers-Danlos syndrome.
    • Obstructive sleep apnoea.
    • Certain hereditary cardiovascular malformations: bicuspid aortic valve, coarctation, Turner's syndrome.

    High-risk examination findings?

    If you suspect acute aortic dissection, move directly to the management section below (999). However, if you examine your patient, the following may support your diagnosis. (The absence of these does not clinically rule out the condition!)

    • Asymmetry of pulse or blood pressure (variation of ≥20mmHg in each arm).
    • Hypotension (or shock), but sometimes hypERtension.
    • Dyspnoea.
    • Focal neurological signs.
    • Murmur of aortic regurgitation.
    • Signs of limb ischaemia.

    Management

    999 to arrange hospital transfer.

    Oxygen and advanced life support (if equipped/skilled to provide this) while waiting.

    Complications can include: aortic rupture/death; pericardial effusion/cardiac tamponade; aortic regurgitation; renal, mesenteric or limb ischaemia.

    Secondary care treatment

    • Type A aortic dissection (ascending aorta or arch): always needs urgent surgical repair.
    • Type B aortic dissection (descending aorta): if stable, medical management to reduce BP and/or heart rate. Surgery may be considered if the patient is unstable/experiencing pain or ischaemia.

    Long-term management

    Surveillance imaging at 1, 3, 6 and 12m, then annually.

    Control other cardiovascular risk factors with tight blood pressure control (systolic <120mmHg).

    Screen relatives if appropriate (secondary care will decide this).

    Acute aortic dissection
  • High-risk symptoms for acute aortic dissection include:

    • Sudden, severe tearing or ripping pain in the chest, back or abdomen.

    Syncope, hypotension, asymmetry or pulse of BP.

    Signs of ischaemia (mesenteric, limb or renal ischaemia).
  • Predisposing conditions include:

    • Family or personal history of aortic disease.
    Some connective tissue disorders.

    Obstructive sleep apnoea.

    Medication: quinolones, glucocorticoids, immunosuppressants, cytotoxic medication.
  • Our role in primary care is in recognising acute presentation and arranging urgent (999) transfer to secondary care, and then in long-term management of other cardiovascular risk factors to reduce risk of recurrence.

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