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Thoracic Aortic Dissection

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

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.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • 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?

    Recommendations
    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.

    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.

  • 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?

    Recommendations
    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.
    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.

  • 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?

    Recommendations
    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.

    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.

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

    Recommendations
    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)
    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)

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

    Recommendations
    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.

    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.

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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