1 / 102

CBP: Aortic Dissection

CBP: Aortic Dissection. Case.

halla-chan
Download Presentation

CBP: Aortic Dissection

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CBP: Aortic Dissection

  2. Case • A 64 year old man presents to the emergency department complaining of sudden sharp 10/10 anterior chest pain with no radiation. His history is remarkable for hypertension, and type II diabetes, but no coronary artery disease or risk factors for venous thromboembolism. His BP is 180/100 on the left, and 162/80 on the right, with no pulsusparadoxus. HR 110, RR 22, O2 sat 96% on r/a, T 37.2. Physical exam shows the patient to be in obvious discomfort, with a clear chest, normal heart sounds, no murmur, and a normal JVP. There are no focal neurological deficits. The electrocardiogram shows evidence of LVH, but no other abnormality. The chest x-ray is on it’s way.

  3. Question 1 • Please go over the ddx of chest pain

  4. Differential diagnoses of Pt admitted to hospital with acute chest discomfort

  5. Approach to the patient with chest discomfort Stable/unstable Symptoms Physical examination ECG Lab works Imaging

  6. The importance of hystory Duration of symptoms (i.e. angina 2-10 min, AMI > 30 min, aortic diss abrupt onset) Quality of symptoms (i.e. AMI heaviness, sharp in pericarditis, ripping sens in AD) Location (i.e. retrosternal with irradiation in AMI,interscapular for AD)

  7. General Appearance may suggest seriousness of symptoms. Vital signs marked difference in blood pressure between arms suggests aortic dissection Palpate the chest wall Hyperesthesia may be due to herpes zoster Complete cardiac examination pericardial rub signs of acute AI or AS Ischemia may result in MI murmur, S4 or S3 Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation Physical examination

  8. Labs Troponin CK-MB Myoglobine

  9. Imaging • CXR (i.e. pneumonia, pnx, AD) • CT (i.e. AD, PE) • TEE (signs of pulmonary hypertension, AD) • Aortogram (AD)

  10. Question 1 • Describe the most common classification systems of aortic dissection (Todd)

  11. Classification systems for Thoracic Aortic Dissections • Time course: Acute vs. Chronic • Anatomical: Ascending, descending or both • Stanford: • Type A: Involving the ascending aorta (with or without descending aortic involvement) • Type B: Involving only the descending aorta • De Bakey: • I: Ascending and Descending aorta • II: Ascending Aorta only • III: Descending Aorta only

  12. Question 2 • Describe the pathophysiology of aortic dissection. (Ibrahim)

  13. Pathophysiology of AAS

  14. Classic Aortic Dissection (AD)

  15. Antegrade Propagation of AD

  16. Retrograde Propagation (Type A)

  17. Intramural Hematoma (IMH)

  18. Penetrating Atherosclerotic Ulcerations

  19. Question 3 • List the major predisposing factors for aortic dissection. (Noemie)

  20. Risk Factors Most common RF Peak incidence in 60-70s M:F =2-5:1 Found in 7-14% of all dissection Most common in 3rd trimester Iatrogenic: 5% of all cases, Cardiac cath, AVR. Trauma @ aortic isthmus

  21. Question 4 • List the most common signs and symptoms of aortic dissection, and highlight the ones which have shown the best positive and negative likelihood ratios. (Erik)

  22. Aortic Dissection Case Based Presentation: Utility of Hx, P/E, and CXR Complications of therapy

  23. List the most common signs and symptoms of aortic dissection, and highlight the ones which have shown the best positive and negative likelihood ratios.

  24. Klompas, JAMA, 2002

  25. The “naked” truth • Majority of data derived from retrospective chart reviews. • Significant selection bias – falsely inflating both sensitivity and specificity. • Do not reflect contemporary practice (lower threshold to scan with 64-MDCT, triple rule-out, etc.)

  26. History • Most patients with [spontaneous] thoracic aortic dissection have severe pain of abrupt onset. • The absence of pain of sudden onset substantively decreases the probability of dissection (negative LR, 0.3; 95% CI, 0.2-0.5); however, the study design of the reports precludes accurate assessment of the sensitivity and specificity of these features.

  27. Physical • Pulse deficits (positive LR, 5.7; 95% CI, 1.4-23.0) or focal neurological deficits (positive LR, 6.6-33.0) greatly increase the likelihood of thoracic aortic dissection in the appropriate clinical setting. • The presence or absence of a diastolic murmur is not useful (positive LR, 1.4; negative LR, 0.9).

  28. CXR • A normal aorta and mediastinum on chest radiograph helps exclude the diagnosis (negative LR, 0.3; 95% CI, 0.2-0.4) but no particular radiographic abnormality is dependably present.

  29. Bare bottom… • Clinical history, examination, and radiography can help rule in aortic dissection but are not sufficiently accurate to rule out the disease.

  30. Question 5 • List the main complications associated with acute aortic dissection, and briefly explain how they occur. (Neil)

  31. Q: List five complications arising from aortic dissection.

  32. Royal college question: • List 5 major complications of aortic dissection

  33. Main complications • 30 % get ischemic complications • In type I mortality due to complications increases 1% per hour • Etiology • Dynamic obstruction • Occlusion of true lumen by false lumen • Static obstruction • Compression, disruption, thrombosis

  34. List of main complications • Tamponade • Acute severe Aortic insufficiency • MI • CVA • Spinal infarct/paraplegia • Aortic rupture • Mesenteric/Renal/Limb ischemia • Pseudoaneurysm

  35. Acute Severe Aortic Insuficiency • Widening of sinotubular junction causing improper coaptation • Diastolic leaflet prolapse from detachment of aortic leaflet commisural attachment • Intimalprolapse • Murmur is typically heard over R sternal border

  36. Acute MI • Occurs in 5 % of Type I dissections • Usually involves R coronary • Often presents as complete heart block or inferior /R sided MI • Mortality if you thrombolyse approaches 70%

  37. Neuro complications • CVA • 10% of type I’s • Carotid occlusion • 5-10% of dissections present with syncope • Spinal • Intercostal arteries • Artery of Adamkiewicz • Can recover if treated early

  38. Case cont’d… • The patient’s chest x-ray shows a wide mediastinum. In the meantime, the patient reports that he is in agony, and his BP rises to 200/120 on the left.

  39. Question 6 • What is the sensitivity and specificity of CXR for aortic dissection? List three CXR findings associated with the condition. (Federico)

More Related