Chest pain: when can it be aortic dissection (or dissection)?

Dissection, or dissection, of the aorta is a cause of acute chest pain; it is uncommon but represents severe severity with regard to the clinical picture

The aorta originates in the left ventricle of the heart; one part tends to go upwards and is called the ascending aorta (the coronary arteries that carry blood to the heart are born from this), it then tends to curve, taking the name of the aortic limb from which the vessels that carry blood to the skull and upper limbs are born, it then tends to descend, taking the name of descending thoracic aorta which enters the abdomen taking the name of abdominal aorta and tends to supply blood to the stomach, liver, intestines, kidneys, etc., it ends in the pelvis where it splits into two arteries that supply blood to the lower limbs.

Aortic dissection, is the rupture of the walls of the aorta, the main arterial blood vessel that connects the heart and the limbs

The artery is made up of 3 layers, called the tonache, which are called the intima, media and adventitia; the intima being the innermost and the adventitia the outermost, as can be deduced from their names.

Tearing of the intima, the innermost layer, may occur under certain conditions, resulting in injury to the vessel. Blood will flow into these laminae creating a ‘false lumen’.

Predisposing to dissection can be aortic aneurysm, where the vessel dilates as a consequence of pathological conditions, such as high blood pressure.

The aneurysm can affect any aortic segment and depending on its size will see the need for corrective surgery in order to avoid possible tears and ruptures.

The consequences of aortic dissection include rupture of the vessel with death in a short time due to shock as a result of internal haemorrhage, to the formation of obstructions due to the false lumen that will cause major ischaemia in the body (brain, abdominal organs including intestines, liver, kidneys, upper or lower limbs) due to the occlusion of the arteries that carry blood from the aorta to the organs just mentioned.

Aortic dissection is quite dangerous but affects about 4 out of 100,000 people

Men between the ages of 40 and 70 are most affected, but young people may also be affected.

At greatest risk are those with connective tissue diseases, such as Marfan syndrome, which causes musculoskeletal, eye, heart and in some cases neurological problems.

In rare cases, aortic dissection will cause complications during cardiovascular interventions such as angioplasty, coronarography, etc.

Symptoms of aortic dissection

The typical symptom of aortic dissection is a very intense chest pain, which is described as stabbing; it is felt posteriorly and tends to shift.

There will be breathlessness when the aortic valve is involved in the aortic dissection, and there will be neurological symptoms when the arteries carrying blood to the brain are involved.

There will be lumbar and/or abdominal pain when the dissection involves the abdominal portion of the aorta, there will be joint pain involving the lower limbs, and there will be pallor and motor difficulty when they are not receiving enough blood.

Symptoms may include cardiovascular collapse and cardiac arrest

For diagnosis, ECG, blood tests, chest X-ray and echocardiogram should be performed initially. These tests will lead to a diagnosis of aortic dissection and allow myocardial infarction and other causes of chest pain to be ruled out.

It may happen that the echocardiogram signals suspicious elements such as: dilated ascending aorta, severe regurgitation of the aortic valve, presence of pericardial effusion, i.e. blood in that space between the heart and the membrane, the pericardium, that surrounds it; and more rarely arrive at the diagnosis if signs of rupture of the ascending aorta are seen.

The main technique for both a correct diagnosis and to establish treatment is contrast-enhanced CT angiography, in order to better observe the thoracic and abdominal aorta and their branches, the site of rupture, the tract involved and the possible involvement of specific branches, and post-treatment controls.

It may happen that a diagnosis will be established by coronarography as these patients will have ECG alterations that are usual in cases of myocardial infarction, and the involvement of the origins of the coronary arteries in the dissection will lead to occlusion and consequently myocardial infarction.

It will then be necessary to perform contrast aortography in the aorta, which will make the presence of false lumen visible and make it possible to establish the correct diagnosis.

Pharmacological treatment

Initially, medication will be administered to manage the pain and to regulate the pressure if it should be too high.

If patients suffer circulatory collapse and cardiac arrest, resuscitation and intubation with the support of drugs such as adrenaline will be required.

Surgery should be performed, especially for so-called type A dissections, which involve the ascending aorta and the aortic arch and should be performed as a matter of urgency

For type B dissections, which involve the descending aorta, the risks of rupture will be lower.

Surgery will be performed to replace the damaged portion of the aorta with a tube made of biocompatible materials; if the aortic valve is involved it will have to be repaired and/or replaced with a prosthesis.

Coronary artery replacement surgery may be performed; the most complex interventions involve the aortic arch as this is where the arteries for cerebral blood supply originate.

Given the high risk to the survival of those affected by this disease, prevention is considered more than essential.

The prognosis is to be considered good, in those patients who have a dilated aorta requiring surgical correction, if there are no peri- or post-operative complications.

In patients with a dilated ascending aorta that does not require surgery, blood pressure should be monitored, beta blockers should be taken, and an electrocardiogram should be performed annually to assess the extent of dilatation and to check for stability or increase.

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