The current evidence on diagnosis and treatment of acute aortic syndrome

Abstract

In their article titled "Acute Aortic Dissection and Intramural Hematoma: A Systematic Review" Mussa et al. highlight the important evidence on diagnosis and treatment of acute aortic syndrome (AAS) (1). AAS describes the presentation of patients with one of a number of life threatening aortic pathologies, including aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). Several studies and meta-analyses have discussed the management of AAS (2-4). Mussa et al. analyzed many studies involving large numbers of patient, and provided new insights; 82 studies with a total of 57,311 patients were included. The information is of great use in the management of AAS. However, the optimal treatment of patients with AAS is still unclear, due to selection bias and the paucity of randomized trials. Only two randomized clinical trials (RCTs) (5,6) were identified, and the remaining 80 were observational cohort studies.T h e a c u t e o n s e t o f t h o r a c i c p a i n w i t h s e v e r e hypertension should raise suspicion for AAS. In the review, 50-81% of patients were males, with ages ranging from 60 to 70 years. The most common risk factor for AD is hypertension, which was observed in 45-100% of patients. Other risk factors include a smoking history, chronic renal insufficiency, chronic obstructive pulmonary disease, and stroke or transient ischemic attack. Although few studies have accurately determined the incidence of AAS, AD is the most common form of AAS, followed by IMH and PAU. A recent analysis of AD reported an incidence of 15 per 100,000 patient-years (7).The diagnosis of AAS can be made using imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), and transesophageal echocardiography (TEE). The ideal diagnostic tool in AAS should have high sensitivity and specificity, and should provide assessment of anatomical aspects for use in management. Early diagnosis and accurate radiological classification is associated with improvement of clinical outcomes in AAS. In the analysis of eligible articles, the sensitivities of CT and MRI for diagnosis of AAS were 100% and 95-100%, respectively. Although MRI provides detailed anatomic information comparable to that of CT, it is limited by availability and long scan times. The authors also reviewed the diagnostic value of TEE. TEE has considerable potential for the diagnosis of AAS. However, TEE does not visualize the aortic arch or abdominal aorta well. These imaging modalities have their advantages and limitations. This important aspect has been reviewed by Macura et al. in detail (8).Mussa et al. came to the conclusion that the lack of studies prevents any suggestions regarding the diagnostic use of serologic biomarkers to improve outcomes. To the best of our knowledge, their review included only limited Editorial

Branches of the brachiocephalic was an independent risk factor for hemorrhagic pulmonary sheath (HPS) patients with acute Stanford A aortic dissection

“…Multiple risk factors could be related to AD, including hypertension, trauma, dyslipidemia, iatrogenic injury, pregnancy, drugs, smoking, chronic renal insufficiency, chronic obstructive pulmonary disease, stroke, Marfan syndrome, etc [5,6,14]. Hypertension is the most important risk factor for AD (77% of AD patients with hypertension) [14].…”

Branches of the brachiocephalic was an independent risk factor for hemorrhagic pulmonary sheath (HPS) patients with acute Stanford A aortic dissection

“…Multiple risk factors could be related to AD, including hypertension, trauma, dyslipidemia, iatrogenic injury, pregnancy, drugs, smoking, chronic renal insu ciency, chronic obstructive pulmonary disease, stroke, Marfan syndrome, etc [5,6,14]. Hypertension is the most important risk factor for AD (77% of AD patients with hypertension) [14].…”

Standardized Nursing Approach to Acute Aortic Dissection Patient: A Practice Update

“…Among these, D-dimer is the most widely used diagnostic biomarker in the clinical practice (Erbel et al, 2014; Suzuki et al, 2013). Several studies have shown that a cut-off level of 500 ng/mL (currently used for pulmonary embolism) is highly sensitive for ruling out classical AAD within the first 6 h of symptom onset (Minegishi et al, 2016; Watanabe et al, 2016). However, D-dimer is a biomarker with high sensitivity but low specificity in AAD, as it may be elevated in many other disorders, including AAD, acute myocardial infarction, and acute pulmonary embolism (Erbel et al, 2014).…”