Disease Description (Causes and Symptoms)
- Definition and pathophysiology: This is a condition in which blood enters the aortic media through a tear in the aortic intima, separating the inner and outer layers. As a result, blood flow is divided into false (occluded) and true (original) channels, which can lead to rupture, organ ischemia, aortic regurgitation, and other complications.
- Major causes: Chronic hypertension (approximately 80% or more of acute cases), hereditary connective tissue disorders (e.g., Marfan syndrome), trauma, aortic coarctation, cystic medial degeneration, and others.
- Major symptoms:
- Sudden-onset severe tearing chest pain or back pain (radiation to the shoulder, abdomen, lower back, etc.)
- Fainting, shortness of breath, anxiety, vomiting, and nausea
- Hypotension and shock (especially in cases of cardiac tamponade or rupture)
- Symptoms of peripheral or organ ischemia: coldness or weakness of the limbs, abdominal pain (organ ischemia), signs of urinary tract obstruction, etc.
- Symptoms of heart failure if aortic regurgitation is present
Treatment Methods
- Initial emergency management
- Immediate hemodynamic stabilization: Reduce the heart rate and ejection pressure with intravenous beta-blockers (e.g., esmolol, metoprolol/intravenous labetalol), followed, if necessary, by an antihypertensive such as nitroprusside.
- Pain control (analgesics), oxygen support, and monitoring (electrocardiography, blood pressure, urine output, etc.).
- Medication treatment
- Acute phase: With IV beta-blockers, the target heart rate is approximately 60 beats/min, and the usual target systolic blood pressure is 100–120 mmHg (adjusted according to the patient’s condition).
- Long term: Antihypertensive medications (beta-blockers first; ARBs/ACE inhibitors, etc., if necessary).
- Surgery and procedures
- Ascending aortic involvement (Stanford A): Emergency open-heart surgery (aortic replacement) is the standard treatment (mortality is high if treatment is delayed).
- Isolated descending aortic involvement (Stanford B): Medical treatment (blood pressure management) is used when the condition is stable and uncomplicated. If complications occur (rupture, persistent pain, organ ischemia, progression of the dissection, etc.), thoracic endovascular aortic repair (TEVAR) or surgery may be considered.
- Surgical principles: Remove the intimal tear and replace the area at risk of rupture with a synthetic blood vessel, using strategies to protect the brain and spinal cord (hypothermia, selective cerebral perfusion, etc.).
- Lifestyle and long-term management
- Strict blood pressure management (the target blood pressure varies by patient, so consult the treating physician). Take medications regularly.
- Avoid lifting excessively heavy objects, strenuous exercise, and stimulant drugs (such as amphetamines).
- Regular imaging follow-up (CT angiography or MRI): initially, after discharge, and long term (a typical schedule may be before discharge, at 1 month, 3 months, 6 months, and 1 year, and annually thereafter or when changes occur); the schedule may vary by individual.
- Prognosis
- If untreated, mortality is very high when the ascending aorta is involved (for example, approximately 50% within 2 days and approximately 90% within 1 month have been reported). Isolated descending involvement has a relatively better prognosis, but there is still a risk of complications.
- Precautions (related to treatment)
- Early diagnosis and rapid hemodynamic stabilization are important in determining the prognosis.
- CT with contrast is useful for diagnosis, but renal function and a history of contrast-agent allergy must be checked.
- During surgery, specialized protective methods are needed to prevent cerebral and spinal cord ischemia (deep hypothermic circulatory arrest, selective perfusion, etc.).
Outpatient Visit Checkpoints (Including Example Questions)
- What to prepare
- A list of currently used medications (exact medication names, doses, and administration times)
- Past medical history (particularly hypertension, cardiovascular disease, surgical history, connective tissue disorders, and genetic diseases)
- Family history (hereditary diseases such as Marfan syndrome)
- Records of when symptoms recently occurred and their characteristics (time pain began, nature, location, whether it radiates, and changes in severity)
- Previous test results (CT, TEE, MRI, chest X-ray, electrocardiogram, etc.) and, if possible, imaging reports/CDs
- Recent blood pressure measurements (values measured at home)
- Situations that should be reported to the healthcare professional in advance during an outpatient visit
- If recent fainting or severe pain has recurred or newly developed, immediate evaluation in the emergency department is recommended.
- Abnormal renal function (history of contrast-agent use) or a history of allergies
- Example questions (for preparing for the appointment)
- Please write down in detail when the pain newly began and how it has changed over time.
- Please confirm whether you are currently taking anticoagulants, antiplatelet agents, or antihypertensive medications.
General Example Questions to Ask the Doctor
- Is surgery (or a procedure) definitely necessary for this condition? If not, why do you recommend medical treatment?
- What are the benefits and risks (complications) of the recommended treatment?
- What should my long-term blood pressure target be, and which medications should be used first?
- What is the schedule for follow-up imaging (CT/MRI)? For how many years and how often should I undergo these tests?
- What symptoms can be expected if the condition recurs or progresses, and what signs mean that I should go to the emergency department immediately?
Examples of Disease-Specific Questions
- Depending on whether I have ascending aortic involvement or only descending aortic involvement, what treatment is recommended (open-heart surgery vs. TEVAR vs. conservative treatment), and what is the basis for that recommendation?
- I am planning a future pregnancy. What risks does this disease pose during pregnancy and childbirth, and what management is recommended (genetic testing, medication adjustments, and recommended delivery method)?