A 75 yo F w/ a history of HTN, smoking presents to the ED w/ intermittent SOB, DOE and L shoulder pain x 4 weeks. She has no chest pain. She is hemodynamically stable. Outpatient 2D echo done earlier that day with suspicious findings, confirmed on CT below. What's the diagnosis? (scroll down for answer)

Answer: Type A Aortic Dissecion (likely subacute)

• Stanford Type A- involves ascending aorta
• Stanford Type B- only involves descending aorta (distal to left subclavian artery)
• Subacute/Chronic  > 14 days
• Retrospective study of 1092 patients w/ TAAD published in European Journal of Cardiothoracic Surgery
• 181 were considered subacute/chronic
• Most had history of prior cardiac/aortic surgery
• Most common presenting symptoms were chest tightness (44%), mild pain and diaphoresis
• Less commonly seen was the typical abrupt tearing, radiating pain seen in acute aortic dissection
• 15 patients were symptom free
• Treatment
• Type A requires surgical repair
• Pain control
• HR control- goal 60 bpm
• BP control
• 1st- negative inotrpy w/ B-blockade (esmolol, labetalol)
• 2nd- vasodilators (nicardipene, nitroglycerin or nitroprusside)

 References

Wu J, Xie E, Qiu J, et al. Subacute/chronic type A aortic dissection: a retrospective cohort study. Eur J Cardiothorac Surg. Feb 2020. 1;57(2)388-396.

Johnson GA, Prince LA. Aortic Dissection and Related Aortic Syndromes. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds.Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY: McGraw-Hill