Chest Pain Plus Video courtesy of Jonas The Doge Pologe
Particularly important for emergency physicians.
• In the diagnostic algorithm, having one or more element of any of the high risk categories gives you one point for that category. Maximum score is three.
• With regard to treatment, labetalol isn’t a bad single agent to start with, but it reduces BP more than HR, and our first therapeutic goal is to reduce HR; metoprolol and esmolol are therefore superior agents. Esmolol has the additional benefit of being rapidly titratable.
• Do not omit aggressive opiate analgesia in your treatment of suspected or confirmed dissection.
• Other risk factors for aortic dissection include conditions associated with increased aortic wall stress, such as hypertension (particularly if uncontrolled); pheochromocytoma; cocaine or other stimulant use; weight lifting or other Valsalva maneuver; deceleration or torsional injury (eg, motor vehicle crash, fall); and coarctation of the aorta. Conditions associated with aortic media abnormalities, which also predispose to aortic dissection, include Marfan syndrome; Ehlers-Danlos syndrome; Bicuspid aortic valve (including prior aortic valve replacement); Turner syndrome; Loeys-Dietz syndrome; familial thoracic aortic aneurysm and dissection syndrome; inflammatory vaculitides such as Takayasu arteritis; giant cell arteritis; and Behcet arteritis. Other conditions associated with aortic media abnormalities include pregnancy; polycystic kidney disease; chronic corticosteroid or immunosuppressive agent administration; and infections involving the aortic wall either from bacteremia or extension of adjacent infection.
• If there is a significant blood pressure difference between the two arms, use the higher number for treatment decisions.
Full guideline available here. Circulation. 2010;121:e266-e369
Outstanding emergency medicine-focused review of the disease here.