Tony Kadysewski's List: Aortic Dissection

• Aortic dissections resulting in rupture have an 80% mortality rate, and 50% of patients die before they even reach the hospital
• About 96% of individuals with aortic dissection present with severe pain that had a sudden onset. It may be described as tearing in nature, or stabbing or sharp in character. 17% of individuals will feel the pain migrate as the dissection extends down the aorta. The location of pain is associated with the location of the dissection. Anterior chest pain is associated with dissections involving the ascending aorta, while interscapular (back) pain is associated with descending aortic dissections.
• Also, individuals suffering from an aortic dissection usually do not present with diaphoresis (profuse sweating).
• Less common symptoms that may be seen in the setting of aortic dissection include congestive heart failure (7%), syncope (9%), cerebrovascular accident (3-6%), ischemic peripheral neuropathy, paraplegia, cardiac arrest, and sudden death. If the individual had a syncopal episode, about half the time it is due to hemorrhage into the pericardium leading to pericardial tamponade.
• Neurologic complications of aortic dissection (i.e., cerebrovascular accident (CVA) and paralysis) are due to involvement of one or more arteries supplying portions of the central nervous system.
• The risk of death due to aortic dissection is highest in the first few hours after the dissection begins, and decreases afterwards. Because of this, the therapeutic strategies differ for treatment of an acute dissection compared to a chronic dissection. An acute dissection is one in which the individual presents within the first two weeks. If the individual has managed to survive this window period, his prognosis is improved. About 66% of all dissections present in the acute phase.
• Individuals who present two weeks after the onset of the dissection are said to have chronic aortic dissections. These individuals have been self-selected as survivors of the acute episode, and can be treated with medical therapy as long as they are stable.
• Medical management is appropriate in individuals with an uncomplicated distal dissection, a stable dissection isolated to the aortic arch, and stable chronic dissections. Patient selection for medical management is very important. Stable individuals who present with an acute distal dissection (typically treated with medical management) still have an 8 percent 30 day mortality.
• The risk of death is highest in the first two years after the acute event, and individuals should be followed closely during this time period. 29% of late deaths following surgery are due to rupture of either the dissecting aneurysm or another aneurysm. In addition, there is a 17% to 25% incidence of new aneurysm formation. This is typically due to dilatation of the residual false lumen. These new aneurysms are more likely to rupture, due to their thinner walls.

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• It is not common to equate severity of angina with risk of fatal cardiac events. There is a weak relationship between severity of pain and degree of oxygen deprivation in the heart muscle (i.e., there can be severe pain with little or no risk of a heart attack, and a heart attack can occur without pain).
• Worsening ("crescendo") angina attacks, sudden-onset angina at rest, and angina lasting more than 15 minutes are symptoms of unstable angina (usually grouped with similar conditions as the acute coronary syndrome). As these may herald myocardial infarction (a heart attack), they require urgent medical attention and are generally treated as a presumed heart attack.
• Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders. This is explained by the concept of referred pain, and is due to the spinal level that receives visceral sensation from the heart simultaneously receiving cutaneous sensation from parts of the skin specified by that spinal nerve's dermatome, without an ability to discriminate the two
• Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation.
• Typical locations for referred pain are arms (often inner left arm), shoulders, and neck into the jaw.
• Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 3 to 5 minutes, and is relieved by rest or specific anti-angina medication.
• Chest pain lasting only a few seconds is normally not angina.
• Some experience "autonomic symptoms" (related to increased activity of the autonomic nervous system) such as nausea, vomiting and pallor.

• Unstable angina

   

  Unstable angina (UA) is defined as angina pectoris that changes or worsens.^[1]

   

  It has at least one of these three features:

   
   
  1. it occurs at rest (or with minimal exertion), usually lasting >10 min;
   
  2. it is severe and of new onset (i.e., within the prior 4–6 weeks); and/or
   
  3. it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously).
   
   

  UA may occur unpredictably at rest which may be a serious indicator of an impending heart attack. What differentiates stable angina from unstable angina (other than symptoms) is the pathophysiology of the atherosclerosis. In stable angina, the developing atheroma is protected with a fibrous cap. This cap (atherosclerotic plaque) may rupture in unstable angina, allowing blood clots to precipitate and further decrease the lumen of the coronary vessel. This explains why an unstable angina appears to be independent of activity.

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• Actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients.

• The actuarial survival rate for high-risk patients (malperfusion, rupture, shock) was 62% at 1 year and 40% at 5 years; the corresponding values for low-risk patients were 94 and 84%, respectively.

• (18.5% overall mortality rate); survival estimates by Kaplan-Meier analysis were 80.4% and 66.1% after 1 and 5 years, respectively.

• In patients presenting with evolving complications such as signs of imminent rupture, expansion, retrograde dissection, or malperfusion syndromes, however, classic open surgery for acute type B aortic dissection carries a 14% to 67% risk of irreversible spinal injury or postoperative mortality
• All patients were initially subjected to intense medical therapy that focused on blood pressure lowering; of these, 189 patients (78%) continued to receive medical therapy for treatment of their acute type B aortic dissection, whereas 26 (11%) underwent surgery, and 27 (11%) received endovascular treatment. The reason for endovascular or surgical treatment was documented in 88% of cases. Recurrent pain, extension of dissection, or refractory hypertension was cited as the reason in 26% of cases,
• This report shows that follow-up mortality rates are relatively high in patients discharged alive from the hospital after acute type B aortic dissection, approaching 1 in 4 patients dying within 3 years.

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• Aortic dissection occurs in approximately 2 out of every 10,000 people. It can affect anyone, but is most often seen in men aged 40 to 70.

• Other symptoms may include:

   
   
  • Changes in thought ability, confusion, disorientation
   
  • Decreased movement, any part of the body
   
  •  Decreased sensation, any part of the body
   
  •  Dizziness 
   
  •  Dry mouth 
   
  •  Dry skin 
   
  •  Fainting 
   
  • Intense anxiety, anguish
   
  •  Nausea and vomiting 
   
  •  Pallor 
   
  •  Profuse sweating (clammy skin)
   
  •  Rapid, weak pulse 
   
  •  Shortness of breath -- difficulty breathing when lying flat (orthopnea)
   
  •  Thirst
• Drugs that lower blood pressure may be prescribed. These drugs may be given through a vein (intravenously). Strong pain relievers are usually needed. Heart medications such as beta-blockers may reduce some of the symptoms.
• Many cases of aortic dissection cannot be prevented.

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