Initial evaluation diagnostic studies-acute aortic syndromes

(Circ 2010;121:e266; EHJ 2018;39:739)

• H&P, incl. bilat BP & radial pulses for symmetry; ECG w/ STE if propagates to cor
• CXR: abnl in 60–90% [↑ mediast. (absence ⊖ LR 0.3), L pl effusion] but cannot r/o AoD
• CT: quick and available, Se ≥93%, Sp 98%; facilitates “triple rule-out” ACS vs. PE vs. AoD
• MRI: Se & Sp >98%, but time-consuming test & not readily available
• TEE: Se >95% prox, 80% for distal; can assess cors/peric/AI; “blind spot” behind trachea
• ⊖ Initial imaging but high clinical suspicion → further studies (⅔ w/ AoD have ≥2 studies)
• D-dimer <500 ng/mL has Se/NPV ~97%, Sp ~50%, but not if high risk and not for IMH
• Risk score (0–3 points): high-risk (eg, genetics, recent Ao manip); aortic pain; e/o perfusion deficit, AI or shock. Score >1 → imaging; ≤1 & DD <500 has NPV >99% (Circ 2018;137:250)