**6. Differential diagnosis**

#### **6.1 Myocardial infarction**

Typically presents with severe substernal or left-sided chest discomfort radiating to shoulders or left arm and shortness of breath and can be differentiated from AD by the typical ECG changes and the rise in the cardiac markers.

#### **6.2 Myocarditis**

Viral myocarditis is often preceded by flu-like symptoms, fever, joint pain, or features of upper respiratory tract infection. These patients usually present with heart failure, and ECHO is done to exclude it from other causes of heart failure.

#### **6.3 Pericarditis or cardiac tamponade**

Presents with sharp chest pain and may have a pericardial friction rub. Patients with tamponade present with cardiogenic shock and have low-voltage ECG with electrical alternans and enlarged cardiac shadow on the Chest X-ray.

### **6.4 Pulmonary embolism**

Classically presents with sudden onset of chest pain, shortness of breath, and hypoxia. In patients suspected to have pulmonary embolism, CT pulmonary angiogram is the definitive investigation to establish the diagnosis.

#### **6.5 Tension pneumothorax**

Patients present with sudden onset of sharp chest pain and desaturation with absent breath sounds. Diagnosis can be established by Chest X-ray.

**73**

*Aortic Dissection*

**6.6 Esophageal rupture**

or pleural effusion.

*DOI: http://dx.doi.org/10.5772/intechopen.89210*

**7. Management of aortic dissection**

300 mcg/kg/min).

calcium channel blocker.

*7.1.1 Acute type A dissection*

stroke, and aortic rupture [24].

Often preceded by history of forceful vomiting, upper gastrointestinal endoscopy or instrumentation. Chest X-ray shows pneumomediastinum, pneumothorax,

**7.1 Acute management of aortic dissection involves immediate resuscitation**

• Intensive blood pressure monitoring preferably with arterial line to maintain SBP between 100 and 120 mmHg and heart rate < 60/min, to prevent the dissection from expanding. This lowering of blood pressure can be attained with:

○ First line—Beta-blockade using labetalol (20 mg iv initially, followed by either 20–80 mg iv boluses every 10 min to a maximal dose of 300 mg or an infusion of 0.5–2 mg/min IV), esmolol (250–500 mcg/kg IV loading dose; then infuse at 25–50 mcg/kg/min, and titrate to maximum dose of

○ Second line—In patients with asthma, allergy, or any contraindication to beta-blockade, calcium channel blockers diltiazem and verapamil can be used.

○ Pain control using iv opioids (tramadol, morphine, fentanyl)

Acute type A dissection is a surgical emergency with a mortality of 1–2% per hour, as these patients are at high risk of complications such as aortic regurgitation, tamponade, myocardial infarction due to compression of the coronary ostium,

This excludes patients with significant comorbidities including prior debilitating stroke, ischemic heart disease, renal failure, malignancy, advancing age, and

These patients should also be assessed for any underlying coronary artery disease or any aortic valve disease by intraoperative transesophageal ECHO to identify

In the International Registry of Aortic Dissection (IRAD) review of 547 patients in which 80 percent of type A patients were treated surgically and the remaining 20 percent were treatment medically, inpatient mortality rates were 27 and 56 percent for surgical and medically treated patients. Medically treated patients were those with advanced comorbidities and aged individuals with poor prognosis [25].

Poor prognostic factors predicting increased mortality in type A patients according to the IRAD study included advanced age, tamponade at presentation, prior

○ Specific management depends on site of dissection

hemorrhagic stroke, which are associated with a bad prognosis.

any wall motion abnormality or aortic valvular defect.

○ Third line—Vasodilator therapy. If blood pressure remains above 120mmHg and heart rate < 60/min, nitroprusside infusion (0.25–0.5 mcg/kg/min titrated to a maximum of 10 mcg/kg/min) can be initiated. This vasodilator therapy should not be used without first lowering heart rate with beta-/
