Diagnostic Essentials for Aortic Dissection

1) Chest, neck, jaw, shoulder back discomfort usually lead to a cardiac diagnosis as number one in the differential. Aortic dissection should always be number two on the list. Neglecting to do this is a frequent error.

2) LISTEN to the patient. Dissection can present with any of the above-mentioned complaints. Particular attention should be paid to the patient with any of these symptoms that wax and wane, or recur over hours or days. This is typical of pre-rupture dissection. Be wary of patients exhibiting this pattern who have multiple return visits to the ER, or internist, within short intervals of time.They were probably misdiagnosed initially. 

3) Scrutinize the cxr and radiology reports. Initial findings on cxr are usually subtle. Look for any aortic prominence, usually along the right side. Mediastinal widening is the classic finding, but it may not be present in early stages. Pericardial prominence is indicative of some degree of intrapericardial bleeding. The pericardium on cxr becomes enlarged and saccular with rounding of the left heart border, particularly in the area of the pulmonary artery.

4) Have a very low threshold for ordering a CT scan. It’s non-invasive, usually readily available and one of the best and simplest way to accurately make the diagnosis. MRI can give more information than CT, but is not as readily available in many institutions. In these days of cost containment, if the diagnosis of dissection is entertained, a quick ER CAT scan is more cost effective than admission and observation, or a malpractice suit!

5) Communicate. Talk directly to the radiologist, cardiologist, etc. If the patient has been seen recently for the same or similar complaints, be suspicious of dissection and obtain all previous records, test results, and speak to the treating physicians.

6) Don’t be fooled by the patient’s age. Dissections will occur in the younger age population, mainly 20-60 years. They are more frequent at the younger end of the spectrum. By contrast AAA occurs most often in the 55-80 year old population.

7) Document everything extensively. This is especially important if the patient refuses to go to the ER from an outside office. I have reviewed several cases in which the patient did this and, subsequently, died at home on the same day.  They resulted in malpractice claims.

Reprinted with permission of MLMIC* Dateline newsletter - Volume 5 No. 1 Spring 2006