Initial Triage and Management of Patients with Acute Aortic Syndromes

AAS represent a spectrum of highly lethal diseases that include AD, IMH, PAU, and BTTAI. It is important that clinicians remain vigilant and maintain a high index of suspicion as these diseases often present with non-specific signs and symptoms. To effectively diagnose and treat AAS, clinicians should undertake a prompt targeted evaluation which is informed by pre -test probability and patient risk factors. Clinicians should consider clinical factors which are associated with vascular abnormalities or increase wall stress as well as the characteristics of the presenting pain. It is crucial to be wary of malperfusion syndromes and consider whether upstream AAS is the proximate cause of the presenting end -organ compromise even in patients without chest pain. In those with a high pre -test probability of AAS, empiric antihypertensive treatment should be initiated before the diagnostic workup is complete (eg, intravenous betablockade prior to CT imaging). In patients with an undifferentiated clinical syndrome where AAS is possible, dedicated aortic imaging with CT (including a "triple-rule-out" scan") can be useful to make the diagnosis. In patients with highpretest probability or confirmed AAS, immediate treatment should be implemented with impulse control aimed at reducing blood pressure and heart rate. Short-acting, rapidly titratable beta-blockers are the mainstay of treatment; however, additional rapidly acting vasodilators may be required to achieve hemodynamic targets. Operative intervention should be informed by the location of the pathology as well as complications and extent of downstream injury, and early surgical consultation is essential. Emergent transfer to subspeciality aortic centers to undergo definitive management is feasible and safe but must be done expeditiously and with close collaboration between the transferring and receiving facility. It is only through clinical vigilance, rapid action, and close coordination across regions and specialties that the care of patients with AAS will improve.