Acute Aortic Syndromes in the ER

Abstract

Acute aortic syndromes (AAS) are pathological conditions which are commonly misdiagnosed, and they are usually mistaken for anginal pain. It is of special interest that ER physicians develop the necessary clinical skills needed to carry out a proper assessment and rapid detection of these diseases. AAS, including aortic dissection, penetrating aortic ulcer, and aortic intramural hematoma, are clinically indistinguishable one from another, and their cardinal manifestation is acute onset of severe chest pain. The high mortality rate and the associated morbidity of AAS are directly related to diagnostic delay, since the onset of symptoms. Quick detection and expedite treatment are fundamental to reduce morbidity and mortality. If left untreated, mortality can spike from 20% during the first 24 hours after symptom onset up to 62% by the 7th day. Specific groups of patients tend to be at high risk for aortic pathology (Marfan syndrome, smokers, hypertension, high-speed trauma, or deceleration). Once an AAS is identified, proper treatment depends on the anatomical distribution and associated complications. Thoracic pain has its focus on the coronary arteries; nonetheless, if an acute coronary syndrome has already been ruled out, and the patient still manifests persistent sharp pain and/or clinical deterioration is present, physicians should be encouraged to search for aortic pathology. A handful of clinical studies are of cardinal importance in the initial diagnostic evaluation, and recently bedside ultrasound has proved its usefulness. CT angiography has been the study of choice for many doctors based on its good and rapid performance.