Land mark concepts in cardiology : Biochemical diagnosis of aortic dissection
Posted Jan 22 2009 5:15pm
Aortic dissection is a complex cardiac problem and a killer disease .Even though it is a fancier to make a diagnosis of aortic dissection in any intractable chest (or back )pain the most common error committed by physicians is failure to recognise it .
Is it possible to diagnose or atleast suspect aortic dissection by a rapid screening biochemical test ?
Yes, it seems so, the D Dimer , a product released consequent to intravascular thrombosis is elevated by >500ng in most of the patients with dissection.
What happens once a diagnosis of aortic dissection is made ?
It is not a great achievement to make a diagnosis of aortic dissection.It is only, a beginning of a long and often tedious decision making process . A real tough task , on hand for the cardiothoracic surgeons. It is a team work , needs the interaction of cardiologists, radiologists and cardiac surgeons to bring an optimal outcome.
The major issues are
Never try to manage this problem in a small hospital or facility. Always send the patient to a teaching hospital ( of course , not all teaching hospital can tackle this either , so enquire about their expertise ! )
No credits for making a simple diagnosis of dissection.One has to exactly locate the entry point and exit points if any.
Aortic root and arch involvement is of major importance in determining the modality of therapy.
Debaky classification is not of academic interest ! it has a purpose . Generally type A dissection(Proximal ) require emergency surgery
Differentiating true lumen from false lumen is of critical importance , it needs a meticulous transesophageal echocardiogram.( Some times one may , never be sure which is true and which is false lumen , funnily .in descending aortic dissection it may never matter for the patient !) Self healing of many dissections with thrombus is possible.
Controlling hypertension with powerful parentral antihypertenive drugs (Labetalol . . . ideally ) is vital.
Side branch involvement (spiral dissections) especially arch vessels and renal arteries make this entity much more complex
Isolated distal dissections and some low risk proximal dissections can indeed be managed conservatively (Also called non surgical ! ) Some cardiologists or even institutions hesitate to put a aortic dissection with medical management .They feel it is inferior form of treatment . . . but realise , it is not necessarily so !)