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Aortic dissection screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3]; Laith Adnan Allaham, M.D.[4]

Overview

Screening guidelines state that an EKG should be obtained for all patients who present with symptoms suspicious for aortic dissection. A chest x ray should be obtained in patients determined to be at low-risk and moderate-risk. In patients in high-risk categories, TEE, CT or MRI should be obtained.

Screening

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (DO NOT EDIT)[1]

Class I
“1. An electrocardiogram should be obtained on all patients who present with symptoms that may represent acute thoracic aortic dissection.
a. Given the relative infrequency of dissection-related coronary artery occlusion, the presence of ST-segment elevation suggestive of myocardial infarction should be treated as a primary cardiac event without delay for definitive aortic imaging unless the patient is at high risk for aortic dissection.[2][3] (Level of Evidence: B)”
“2. The role of chest x-ray in the evaluation of possible thoracic aortic disease should be directed by the patient’s pretest risk of disease as follows:
a. Intermediate risk: Chest x-ray should be performed on all intermediate-risk patients, as it may establish a clear alternate diagnosis that will obviate the need for definitive aortic imaging. (Level of Evidence: C)
b. Low risk: Chest x-ray should be performed on all low-risk patients, as it may either establish an alternative diagnosis or demonstrate findings that are suggestive of thoracic aortic disease, indicating the need for urgent definitive aortic imaging. (Level of Evidence: C)”
“3. Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening.[4][5][6][7][8][9][10] (Level of Evidence: B)”
Class III (No Benefit)
“1. A negative chest x-ray should not delay definitive aortic imaging in patients determined to be high risk for aortic dissection by initial screening. (Level of Evidence: C)”

Genetic Syndromes of Familial Thoracic Aortic Aneurysms and Dissections (DO NOT EDIT) [1]

Class IIa
“1. Sequencing of the ACTA2 gene is reasonable in patients with a family history of thoracic aortic aneurysms and/or dissections to determine if ACTA2 mutations are responsible for the inherited predisposition.[11][12][13][14][15][16] (Level of Evidence: B)”
Class IIb
“1. Sequencing of other genes known to cause familial thoracic aortic aneurysms and/or dissection (TGFBR1, TGFBR2, MYH11) may be considered in patients with a family history and clinical features associated with mutations in these genes.[11][12][13][14][15][16] (Level of Evidence: B)”
“2. If one or more first-degree relatives of a patient with known thoracic aortic aneurysm and/or dissection are found to have thoracic aortic dilatation, aneurysm, or dissection, then referral to a geneticist may be considered. (Level of Evidence: C)”

References

  1. ↑ 1.0 1.1 Hiratzka LF, Bakris GL, Beckman JA; et al. (2010). “2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine”. Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780. Unknown parameter |month= ignored (help)
  2. ↑ Hagan PG, Nienaber CA, Isselbacher EM; et al. (2000). “The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease”. JAMA. 283 (7): 897–903. PMID 10685714. Unknown parameter |month= ignored (help)
  3. ↑ Klompas M (2002). “Does this patient have an acute thoracic aortic dissection?”. JAMA. 287 (17): 2262–72. PMID 11980527. Unknown parameter |month= ignored (help)
  4. ↑ Yoshida S, Akiba H, Tamakawa M; et al. (2003). “Thoracic involvement of type A aortic dissection and intramural hematoma: diagnostic accuracy–comparison of emergency helical CT and surgical findings”. Radiology. 228 (2): 430–5. doi:10.1148/radiol.2282012162. PMID 12819341. Unknown parameter |month= ignored (help)
  5. ↑ Sommer T, Fehske W, Holzknecht N; et al. (1996). “Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging”. Radiology. 199 (2): 347–52. PMID 8668776. Unknown parameter |month= ignored (help)
  6. ↑ Zeman RK, Berman PM, Silverman PM; et al. (1995). “Diagnosis of aortic dissection: value of helical CT with multiplanar reformation and three-dimensional rendering”. AJR Am J Roentgenol. 164 (6): 1375–80. PMID 7754876. Unknown parameter |month= ignored (help)
  7. ↑ Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y (2006). “Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis”. Arch. Intern. Med. 166 (13): 1350–6. doi:10.1001/archinte.166.13.1350. PMID 16831999. Unknown parameter |month= ignored (help)
  8. ↑ Nienaber CA, von Kodolitsch Y, Nicolas V; et al. (1993). “The diagnosis of thoracic aortic dissection by noninvasive imaging procedures”. N. Engl. J. Med. 328 (1): 1–9. doi:10.1056/NEJM199301073280101. PMID 8416265. Unknown parameter |month= ignored (help)
  9. ↑ Erbel R, Engberding R, Daniel W, Roelandt J, Visser C, Rennollet H (1989). “Echocardiography in diagnosis of aortic dissection”. Lancet. 1 (8636): 457–61. PMID 2563839. Unknown parameter |month= ignored (help)
  10. ↑ Börner N, Erbel R, Braun B, Henkel B, Meyer J, Rumpelt J (1984). “Diagnosis of aortic dissection by transesophageal echocardiography”. Am. J. Cardiol. 54 (8): 1157–8. PMID 6496346. Unknown parameter |month= ignored (help)
  11. ↑ 11.0 11.1 Pannu H, Fadulu VT, Chang J, Lafont A, Hasham SN, Sparks E; et al. (2005). “Mutations in transforming growth factor-beta receptor type II cause familial thoracic aortic aneurysms and dissections”. Circulation. 112 (4): 513–20. doi:10.1161/CIRCULATIONAHA.105.537340. PMID 16027248.
  12. ↑ 12.0 12.1 Guo DC, Pannu H, Tran-Fadulu V, Papke CL, Yu RK, Avidan N; et al. (2007). “Mutations in smooth muscle alpha-actin (ACTA2) lead to thoracic aortic aneurysms and dissections”. Nat Genet. 39 (12): 1488–93. doi:10.1038/ng.2007.6. PMID 17994018.
  13. ↑ 13.0 13.1 Zhu L, Vranckx R, Khau Van Kien P, Lalande A, Boisset N, Mathieu F; et al. (2006). “Mutations in myosin heavy chain 11 cause a syndrome associating thoracic aortic aneurysm/aortic dissection and patent ductus arteriosus”. Nat Genet. 38 (3): 343–9. doi:10.1038/ng1721. PMID 16444274.
  14. ↑ 14.0 14.1 Loeys BL, Schwarze U, Holm T, Callewaert BL, Thomas GH, Pannu H; et al. (2006). “Aneurysm syndromes caused by mutations in the TGF-beta receptor”. N Engl J Med. 355 (8): 788–98. doi:10.1056/NEJMoa055695. PMID 16928994.
  15. ↑ 15.0 15.1 Stheneur C, Collod-Béroud G, Faivre L, Gouya L, Sultan G, Le Parc JM; et al. (2008). “Identification of 23 TGFBR2 and 6 TGFBR1 gene mutations and genotype-phenotype investigations in 457 patients with Marfan syndrome type I and II, Loeys-Dietz syndrome and related disorders”. Hum Mutat. 29 (11): E284–95. doi:10.1002/humu.20871. PMID 18781618.
  16. ↑ 16.0 16.1 Guo DC, Papke CL, Tran-Fadulu V, Regalado ES, Avidan N, Johnson RJ; et al. (2009). “Mutations in smooth muscle alpha-actin (ACTA2) cause coronary artery disease, stroke, and Moyamoya disease, along with thoracic aortic disease”. Am J Hum Genet. 84 (5): 617–27. doi:10.1016/j.ajhg.2009.04.007. PMC 2680995. PMID 19409525.

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