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Diagnosis and management of acute aortic syndromes in the emergency department

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Abstract

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and d-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100–120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

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Funding

PN received grant money from Università degli Studi di Firenze (16DPPN); FM received Grant money from the Italian Ministry of Health (GR-2013-02355449) and honoraria from Boehringer Ingelheim and Bayer (lectures and educational activities).

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Authors and Affiliations

  1. S.C.U. Medicina d’Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy

    Fulvio Morello & Marco Santoro

  2. Dipartimento di Scienze Mediche, Università degli Studi di Torino, Torino, Italy

    Fulvio Morello

  3. Department of Vascular Surgery, Careggi University Hospital, Firenze, Italy

    Aaron Thomas Fargion

  4. Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy

    Stefano Grifoni & Peiman Nazerian

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  1. Fulvio Morello
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  2. Marco Santoro
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Correspondence to Peiman Nazerian.

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Morello, F., Santoro, M., Fargion, A.T. et al. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med 16, 171–181 (2021). https://doi.org/10.1007/s11739-020-02354-8

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