Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection

Official 2014 guideline from the American College of Emergency Physicians.

These guideline summaries are shared for educational purposes only and are not intended to direct patient care. For detail on the specific recommendations and information about the evidence considered by the guideline developer, we encourage you to go to the original guideline statement cited below.

Strength

Clinical Predictors

Level C

In an attempt to identify patients at very low risk for acute nontraumatic thoracic aortic dissection, do not use existing clinical decision rules alone. The decision to pursue further workup for acute nontraumatic aortic dissection should be at the discretion of the treating physician.

Diagnosis

D-dimer

Level C

In adult patients with suspected nontraumatic thoracic aortic dissection, do not rely on D-dimer alone to exclude the diagnosis of aortic dissection.

Imaging

Level B

In adult patients with suspected nontraumatic thoracic aortic dissection, emergency physicians may use computed tomography (CT) angiogram to exclude thoracic aortic dissection because it has accuracy similar to that of transesophageal echocardiogram (TEE) and magnetic resonance angiogram (MRA).

Level B

In adult patients with suspected nontraumatic thoracic aortic dissection, do not rely on an abnormal bedside transthoracic echocardiogram (TTE) result to definitively establish the diagnosis of thoracic aortic dissection.

Level C

In adult patients with suspected nontraumatic thoracic aortic dissection, immediate surgical consultation or transfer to a higher level of care should be considered if a transthoracic echocardiogram (TTE) is suggestive of aortic dissection. [Consensus recommendation]

Intervention

Level C

In adult patients with acute nontraumatic thoracic aortic dissection, decrease blood pressure and pulse if elevated. However, there are no specific targets that have demonstrated a reduction in morbidity and mortality.

Literature

Original/Primary Reference

Diercks DB, Promes SB, Schuur JD, et al. American College of Emergency Physicians. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Suspected Acute Nontraumatic Thoracic Aortic Dissection. Ann Emerg Med. 2015;65(1):

Summary By

Eric Steinberg, DO, MEHP

What do the ratings mean?

Level A

Generally accepted principles for patient care that reflect a high degree of clinical certainty (ie, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).

Level B

Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (ie, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).

Level C

Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of any adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.