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Acute aortic syndromes: An internist's guide to the galaxy

  • Author Footnotes
    1 These authors contributed equally.
    Fulvio Morello
    Footnotes
    1 These authors contributed equally.
    Affiliations
    S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy

    Dipartimento di Scienze Mediche, Università degli Studi di Torino, Italy
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  • Author Footnotes
    1 These authors contributed equally.
    Paolo Bima
    Footnotes
    1 These authors contributed equally.
    Affiliations
    S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy

    Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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  • Matteo Castelli
    Affiliations
    Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
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  • Peiman Nazerian
    Correspondence
    Corresponding author.
    Affiliations
    Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
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  • Author Footnotes
    1 These authors contributed equally.
Published:October 11, 2022DOI:https://doi.org/10.1016/j.ejim.2022.10.003

      Highlights

      • Acute aortic syndromes should be considered in differential diagnosis in all patients presenting with acute truncal pain, syncope, neurologic deficit or limb ischemia.
      • The clinical presentation can be classified as critical, typical or atypical. Inflammation, thrombosis and organ malperfusion engaged by acute aortic syndromes may dominate the clinical picture.
      • In presence of compatible symptoms, selection of patients needing CT angiography should be made by integration of standardized clinical probability assessment, focus cardiac ultrasound and d-dimer testing.
      • Focus cardiac ultrasound is most useful for identification of patients requiring CT angiography without delay, while a negative d-dimer test safely rules out acute aortic syndromes in patients at low clinical probability.
      • Anti-impulse medical therapy with target heart rate of 50–60 bpm and systolic blood pressure <100 mmHg, pain management and aorta specialist consultation constitute the standard of care.

      Abtract

      Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.

      Keywords

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