What ER Doctors should be looking for!
information should the emergency room team obtain from a
patient with chest pain?
Upon arrival in the emergency room, the patient should be
asked to clearly describe the pain—its location and
severity, and the extent to which it is different from
previous pain. While gathering the medical history, the
patient should be asked about any known diagnosis of the
Marfan syndrome or other form of aortic disease, as well as
any knowledge about the status of his or her aorta from
previous tests. Many people with the Marfan syndrome are
knowledgeable about their medical status. However, emergency
department physicians should be able to evaluate individuals
with suspected aortic dissection, independent of the Marfan
syndrome. The clinical features of aortic dissection are not
unique to people with the Marfan syndrome, except that the
incidence of dissection in individuals under the age of 45
is markedly increased in people with the Marfan syndrome and
other forms of aortic disease.
What part of the physical exam raises the possibility of
an aortic dissection?
During the physical examination, it is important to check
the blood pressure in both arms and the pulses in both
wrists, both legs and both sides of the neck over the
carotid arteries. If an aortic dissection is present, a
difference in blood pressure can sometimes be found between
the arms and the differences in the pulse can be detected.
High blood pressure could indicate a number of factors:
- A predisposing factor to aortic dissection.
- Pain from the dissection
- A partially or completely blocked artery to one or
An abnormally large difference between the top (systolic)
blood pressure and the bottom (diastolic) blood pressure,
could be due to a leakage of blood back into the heart
Very low blood pressure can also occur. Many people with the
Marfan syndrome are treated with medications to keep their
blood pressure at the very bottom of the normal range. It is
important to ask patients with a known diagnosis of the
Marfan syndrome their normal blood pressure so that, if the
emergency providers detect a blood pressure of, for example,
100/60, they are aware that it is the patient's usual blood
pressure and not the result of an acute event. This is
essential so that doctors do not try to raise the blood
pressure, which would be a potential disaster in the setting
of a dissection.
What tests are necessary to confirm a diagnosis of an
Once the possibility of a dissection has been raised, an
imaging study of the aorta is needed. A pain that starts at
the front of the chest would suggest that the aorta near the
heart is involved. In this situation, a standard
echocardiogram may be useful. If the pain arises in the back
of the chest or in the abdomen, a computed tomographic scan
(which is most sensitive when radiographic x-ray contrast is
given), transesophogeal echocardiogram, or magnetic
resonance imaging study is necessary.
The particular test would depend on which of these tests is
most readily available, and most expertly done and
If a patient is having severe anterior chest pain, the
emergency room physician may first consider a myocardial
infarction or an inflammation of the lining around the
heart. However, if the electrocardiogram doesn't show an
obvious heart attack, and pericardial inflammation is being
considered, a test such as an echocardiogram could document
that possibility. In that situation, if the aorta is
dissected close to the heart, the dissection may appear on
the echocardiogram and the correct diagnosis would be
achieved without having had to consider it as a first
What are other possible causes of chest pain?
There are many other causes for the type of chest pain
associated with an aortic dissection. These include a heart
attack (myocardial infarction) and inflammation of the
lining around the heart (pericarditis). Problems with the
esophagus and the spine also could cause pain in the same
general area, although they tend to have different symptoms.
Can an aortic dissection be stabilized?
Dissections that begin away from the heart (Type B or distal
dissection) often can be stabilized and may not require
immediate surgery. However, a dissection that starts near
the heart (Type A or proximal)—in the part of the aorta
leading up to the neck—does not tend to stabilize. A
dissection in this area is exposed to the full force with
which the heart pumps blood on each beat, which extends the
tear. Proximal dissections require immediate surgical
Information gathered from the imaging technology can
indicate the likelihood of stabilization. In addition, it is
important to see if the aorta in any segment is 5-6 cm or
more in diameter, which would indicate elective, if not
immediate, surgery. An aorta of 5-6 cm means the aortic wall
has been thinned and stretched, and is at a great risk for
further enlargement and, potentially, rupture.
How can a dissection be stabilized?
Upon diagnosis of a dissection, it is important to lower the
blood pressure to the bottom end of the normal range, or
even a little lower, with medication. In addition, either a
beta blocker or verapamil is used to slow the pulse and make
the heart beat with less force. These medications can be
given intravenously in order to be effective in minutes.
In a dissection that starts away from the heart, if the
blood pressure stabilizes, the pain stops, and there's no
compromise of blood flow to the kidneys and other vital
organs, then the approach is usually based on aggressive use
of medications to lower blood pressure to as low as 90-100
mm Hg and to slow the pulse, and careful monitoring to
ensure that the aorta doesn't enlarge further.
Surgery would be considered if the tear in the descending
aorta seems to stabilize, but then grows progressively, or
if there is a rapid rate of change in an aorta size not yet
considered to be at risk for rupture. Regardless of the
cause of an aortic aneurysm, surgery should be considered
once the aortic diameter reaches twice normal. On average,
this corresponds to 5-6 cm for the thoracic aorta. A lower
threshold is recommended for people with the Marfan syndrome
with severe aortic regurgitation, family history of aortic
dissection or the need for other major surgery.
A patient who is extremely anxious may be aided by some
sedation, which may help potentiate the effects of medicine
and control blood pressure. However, it is important for
patients in this situation to be awake and alert enough to
be able to describe the pain and symptoms. If someone has a
large dissection that begins near the heart, or the tear is
very extensive and they continue to have pain even after the
blood pressure has been brought down to a low level,
proceeding with surgery as soon as the surgical team is
assembled is essential. In the brief time before surgery,
medication to control pain can be used without loss of
needed diagnostic information.
When is surgery necessary?
Symptomatic ascending aortic dissections or aneurysms,
whether acute or chronic, require emergency surgical
treatment. Acute descending aortic dissections require
admission to intensive care for monitoring and blood
pressure control. Those with pain that does not resolve with
blood pressure control will need urgent surgery. Those with
evidence of organ ischemia (kidneys, bowel, spinal cord)
will also require urgent surgery. In patients with chronic
descending aortic dissections, pain may indicate impending
rupture and, therefore, warrant urgent surgery.
In general, the decision for immediate surgery is based on
indicators of especially high risk, such as the presence of
a proximal dissection, or continued pain despite blood
Other indicators for urgent surgery are:
- Evidence of fluid in the pericardial sac around the
heart with a dissection that comes back to the heart,
which suggests that the tear is going into the pericardial
- Evidence of marked enlargement of the dissected aorta
- Evidence of blood leakage into tissue by contrast CT
scan or transesophogeal echocardiogram.
- Evidence that blood flow to one or more vital organs
is being compromised.
- Evidence of an intramural hematoma, a localized
collection of blood within the aortic wall that can
accumulate before the dissection progresses along the
length of the aorta. Intramural hematomas indicate an
impending dissection, and should be treated in an