eMedicine Specialties > Emergency Medicine > Cardiovascular

Dissection, Aortic: Follow-up

Author: John M Wiesenfarth, MD, FACEP, FAAEM, Associate Clinical Professor, Division of Emergency Medicine, University of California Davis; Chief, Department of Emergency Medicine, Kaiser-Permanente Hospital Sacramento/Roseville
Contributor Information and Disclosures

Updated: Aug 28, 2009

Follow-up

Further Inpatient Care

  • Patients with symptomatic dissection should undergo immediate repair, especially if it is leaking or expanding.
  • Symptomatic patients require admission to a center experienced in cardiopulmonary bypass and operative care.
  • Completely asymptomatic patients may have their repair performed electively but may require admission to expedite their evaluation or for preoperative stabilization of their condition.
  • Patients with chest pain should undergo serial ECGs and CK determinations if AMI is indicated.

Further Outpatient Care

  • Follow-up examinations with radiologic studies are recommended at 3-month intervals for the first year and every 6 months for the next 2 years.
  • After this, follow up annually.

Transfer

  • Symptomatic patients require care at a facility equipped to perform cardiopulmonary bypass with aortic and/or valvular repair.
  • Contact the receiving physician as soon as possible to transfer patients before their condition deteriorates.
  • Early airway management is indicated in the presence of hemoptysis or stridor.
  • If coronary insufficiency is suspected, nitrates may be used, but therapy with thrombolytic agents and aspirin should be avoided.
  • Patients should be monitored and accompanied by personnel capable of resuscitation.
  • If a prolonged ground transport time is anticipated, consider air transport.

Prognosis

  • On the basis of his experience, Crawford has stated that "no patient should be considered cured of the disease."
  • The 5-year survival rate is about 75% whether the patient is treated medically or surgically.
  • The 10-year survival rate is between 40% and 69% for both surgically and medically treated dissections.
  • In the pretreatment era, the 1-year survival rate was 5-10%.
  • Reoperation may be necessary for late complications.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose (especially in patients presenting with chest pain)
  • Use of thrombolytics in the patient presenting with chest pain and ECG changes
    • Multiple case reports describe patients who received thrombolytics and were found later to have a dissection. The diagnosis of aortic dissection can be subtle.
    • The diagnosis depends on clinical suspicion, with contributory findings on history, physical examination, and imaging studies.
    • Obtaining a chest radiograph prior to administering thrombolytics is considered prudent.
    • Checking blood pressures in both arms and listening for carotid bruits also can help diagnose aortic dissection prior to administering thrombolytics. The entire clinical picture must be taken into account.
 


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References
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References

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Further Reading

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Contributor Information and Disclosures

Author

John M Wiesenfarth, MD, FACEP, FAAEM, Associate Clinical Professor, Division of Emergency Medicine, University of California Davis; Chief, Department of Emergency Medicine, Kaiser-Permanente Hospital Sacramento/Roseville
John M Wiesenfarth, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Joseph J Sachter, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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