Thoracic Aortic Dissection

Thoracic Aortic Dissection (Adult – Nontraumatic)

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection (October 2014)

Complete Clinical Policy on Suspected Acute Nontraumatic Thoracic Aortic Dissection


Scope of Application. This guideline is intended for physicians working in emergency departments.

Inclusion Criteria. This guideline is intended for adult patients aged 18 years and older presenting to the ED with suspected acute nontraumatic thoracic aortic dissection.

Exclusion Criteria. This guideline is not intended to be used for patients with traumatic aortic dissection, for pediatric patients, or for pregnant patients.

Critical Questions

1. In adult patients with suspected acute nontraumatic thoracic aortic dissection, are there clinical decision rules that identify a group of patients at very low risk for the diagnosis of thoracic aortic dissection?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. In an attempt to identify patients at very low risk for acute nontraumatic thoracic aortic dissection, do not use existing clinical decision rules alone. The decision to pursue further workup for acute nontraumatic aortic dissection should be at the discretion of the treating physician.

2. In adult patients with suspected acute nontraumatic thoracic aortic dissection, is a negative serum D-dimer sufficient to identify a group of patients at very low risk for the diagnosis of thoracic aortic dissection?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. In adult patients with suspected nontraumatic thoracic aortic dissection, do not rely on D-dimer alone to exclude the diagnosis of aortic dissection.

3. In adult patients with suspected acute nontraumatic thoracic aortic dissection, is the diagnostic accuracy of computed tomography angiogram (CTA) at least equivalent to transesophageal echocardiogram (TEE) or magnetic resonance angiogram (MRA) to exclude the diagnosis of thoracic aortic dissection?

Level A recommendations. None specified.

Level B recommendations. In adult patients with suspected nontraumatic thoracic aortic dissection, emergency physicians may use CTA to exclude thoracic aortic dissection because it has accuracy similar to that of TEE and MRA.

Level C recommendations. None specified.

4. In adult patients with suspected acute nontraumatic thoracic aortic dissection, does an abnormal bedside transthoracic echocardiogram (TTE) establish the diagnosis of thoracic aortic dissection?

Level A recommendations. None specified.

Level B recommendations. In adult patients with suspected nontraumatic thoracic aortic dissection, do not rely on an abnormal bedside TTE result to definitively establish the diagnosis of thoracic aortic dissection.

Level C recommendations. In adult patients with suspected nontraumatic thoracic aortic dissection, immediate surgical consultation or transfer to a higher level of care should be considered if a TTE is suggestive of aortic dissection. (Consensus recommendation)

5. In adult patients with acute nontraumatic thoracic aortic dissection, does targeted heart rate and blood pressure lowering reduce morbidity or mortality?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. In adult patients with acute nontraumatic thoracic aortic dissection, decrease blood pressure and pulse if elevated. However, there are no specific targets that have demonstrated a reduction in morbidity and mortality.

Purpose of ACEP’s Clinical Policies

Clinical Findings and Strength of Recommendations

 
 
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