{"id":3056,"date":"2016-02-29T19:21:24","date_gmt":"2016-02-29T19:21:24","guid":{"rendered":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/?p=3056"},"modified":"2016-10-19T20:56:51","modified_gmt":"2016-10-19T20:56:51","slug":"thoracic-aortic-dissection-great-masquerader","status":"publish","type":"post","link":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/thoracic-aortic-dissection-great-masquerader\/","title":{"rendered":"Thoracic Aortic Dissection: The Great Masquerader"},"content":{"rendered":"Not all chest pain is a heart attack. While acute coronary syndrome (ACS) may be the most common serious cause of chest pain, clinicians must keep other dangerous conditions in the differential diagnosis and eliminate the possibilities based on the patient\u2019s history, risk stratification, physical exam and diagnostic testing. One of the most dramatic and perplexing causes for acute chest pain, other than ACS, is thoracic aortic dissection.\nThoracic aortic dissection (TAD) is a Great Masquerader. It can present with symptoms extending from head to toe and can mimic ACS, TIA or stroke, back strain, abdominal catastrophes and extremity conditions. TAD is an actor that likes to travel; it may first afflict the patient with chest pain that abates, only to reappear in the neck, back, abdomen or extremities. It is a sneaky character that can confound even the most astute clinician as the patient continues to have acute chest pain despite normal diagnostics, including ECG, chest X-ray and troponins. Sometimes the diagnosis of TAD is completely masked and simply cannot be made. Aortic disease is one of the most difficult of all medical diagnoses.\nEach year in the U.S., there are about 25,000 cases of TAD, making it 2-3 times more common than ruptured abdominal aortic aneurysm but much less common than ACS or pulmonary embolism. Unfortunately, the diagnosis is unsuspected and delayed in more than 1\/3 of patients with TAD, and the outcome in undiagnosed\/untreated patients is often fatal. Although the biggest risk for clinicians is the delay or failure to diagnose TAD, delays in appropriate treatment also pose a threat to patient safety.\nTAD, however, is not a perfect criminal and very often leaves clues to its existence. It is up to the practitioner to be a shrewd detective with an open mind and avoid the common cognitive errors of anchoring or premature closure. Symptoms of TAD are often erroneously attributed to other more common conditions, even when all the pieces of the puzzle do not perfectly fit. The detective clinician should maintain suspicion for TAD when evaluating the patient with any of the following:\n\nAbrupt onset of severe pain in the chest, back or abdomen; described as ripping, tearing, sharp or stabbing.\nSignificant chest pain continues despite normal ECG and troponins.\nSymptoms change over space and time \u2013 migrate, radiate, or come and go.\nMultiple organ systems are involved: cardiac, neurologic, abdominal, renal, peripheral circulation.\n\nRisk factor analysis can reveal important clues to the diagnosis, but clinicians often simply do not assess for TAD risk factors. There are several high-risk conditions, pain features, and exam features that are part of the \u201cAortic Disease Detection Score\u201d that should be considered in the evaluation of patients with any of the clinical presentations outlined above. These risk features include:\n\nHigh-risk conditions: hypertension, Marfan Syndrome, connective tissue disease, family history of aortic disease or unexplained sudden death, aortic valve disease, recent aortic manipulation, known thoracic aortic aneurysm\nHigh-risk pain features: chest, back or abdominal pain that is abrupt or severe AND described as ripping, tearing, sharp or stabbing\nHigh-risk exam features: pulse deficit, systolic BP differential, focal neurologic deficit in conjunction with pain, new murmur of aortic insufficiency, hypotension or shock state\n\nConfronted with seemingly unconnected and inexplicable signs and symptoms, clinicians are sometimes left in a quandary regarding the appropriate diagnostic workup. The ECG and troponins are usually normal, and the chest X-ray is often abnormal but non-specific. The definitive diagnosis is made by advanced imaging (CTA of thoracic aorta, MRI, or TEE), which is recommended in all patients stratified as high-risk and in intermediate and low-risk patients when TAD remains in the differential diagnosis.\nComprehensive guidelines for the diagnosis and management of patients with TAD were published in 2010; these are a must-read. With a mortality rate of 1% to 2% per hour for the first 24 to 28 hours, TAD qualifies as a \u201cseconds-to-minutes\u201d emergency that demands super-STAT evaluation and treatment. But first, clinicians must remember that not all chest pain is a heart attack and keep the Great Masquerader in mind.\nInterested in learning more for CME?\nReview our courses:\n\nThoracic Aortic Dissection in Emergency Medicine\nThoracic Aortic Dissection & Marfan Syndrome\nThoracic Aortic Dissection Case Studies\nThoracic Aortic Dissection in Hospital Medicine – Hospitalist\n\n \nAdditional Resources & Links\n\u00a0American Heart Association. www.heart.org\n\u00a0Hiratzka LF, et al. 2010 ACCF\/AHA\/AATS\/ACR\/ASA\/SCAI\/SIR\/STS\/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 2010;121(13):e266-e369.\nThe Thoracic Aortic Disease (TAD) Coalition is a group of organizations and individuals who share a common mission of preventing premature deaths due to thoracic aortic aneurysm and dissection. www.tadcoalition.org\nThe John Ritter Foundation for Aortic Health. www.johnritterfoundation.org\nThe Marfan Foundation www.marfan.org\n","protected":false},"excerpt":{"rendered":"

Not all chest pain is a heart attack. While acute coronary syndrome (ACS) may be the most common serious cause of chest pain, clinicians must keep other dangerous conditions in the differential diagnosis and eliminate the possibilities based on the patient\u2019s history, risk stratification, physical exam and diagnostic testing. One of the most dramatic and…Read More<\/a><\/p>\n","protected":false},"author":3,"featured_media":4829,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"om_disable_all_campaigns":false,"footnotes":""},"categories":[8,20,21,25],"tags":[],"acf":[],"_links":{"self":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts\/3056"}],"collection":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/comments?post=3056"}],"version-history":[{"count":9,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts\/3056\/revisions"}],"predecessor-version":[{"id":3811,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/posts\/3056\/revisions\/3811"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/media\/4829"}],"wp:attachment":[{"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/media?parent=3056"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/categories?post=3056"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/test.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/tags?post=3056"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}