Acute aortic syndrome: Difference between revisions

	Acute aortic syndrome Microchapters
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Patient Information
Overview
Classification • Aortic dissection • Aortic intramural hematoma • Penetrating atherosclerotic aortic ulcer
Differentiating Acute Aortic Syndrome from other Diseases
Causes
Guidelines

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Latest revision as of 18:44, 3 May 2023

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2], Sabawoon Mirwais, M.B.B.S, M.D.[3]

Overview

Acute aortic syndrome (AAS) describes a constellation of emergency conditions with a similar clinical feature that involves the aorta. These include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer. It is possible for AAS to get complicated by acute coronary syndrome. The term was introduced in 2001.

Classification

Acute aortic syndrome is classified into 5 entities as follows:^[2]^[3]

Type I: classic aortic dissection involving an intimal layer between the true and false lumen (with no communication between the two lumen)
Type II: aortic dissection with medial rupture and the subsequent intramural hematoma formation
Type III: subtle aortic dissection with bulging of the aortic wall
Type IV: aortic dissection due to plaque rupture and subsequent ulceration
Type V: iatrogenic/traumatic dissection

Differentiating Acute Aortic Syndrome from other Diseases

Acute aortic syndrome should be differentiated from other conditions causing signs and symptoms such as chest pain, dyspnea, back pain and etc.
For more information on the differential diagnosis of the acute aortic syndrome click here.

Causes

Causes include aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer or a thoracic aneurysm that has become unstable.^[4]
Basically, AAS can be caused by a breakdown on the wall of the aorta that involves the tunica intima and/or media.^[5]
For more information on aortic dissection causes click here.
For more information on aortic intramural hematoma causes click here.
For more information on penetrating atherosclerotic aortic ulcer causes click here.

Guidelines

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)^[6]


Recommendations	Class	Level	References
History and clinical assessment
"In all patients with suspected AAS, pre-test probability assessment is recommended, according to the patient’s condition, symptoms, and clinical features."	I	B	^[7]
Laboratory testing
"In case of suspicion of AAS, the interpretation of biomarkers should always be considered along with the pretest clinical probability."	IIa	B
"In case of low clinical probability of AAS, negative D-dimer levels should be considered as ruling out the diagnosis."	IIa	C	^[8]^[9]^[10]^[11]
"In case of intermediate clinical probability of AAS with a positive (point-of-care) D-dimer test, further imaging tests should be considered."	IIa	B	^[8]^[9]
"In patients with high probability (risk score 2 or 3) of AD, testing of D-dimers is not recommended."	III	C
Imaging
"TTE is recommended as an initial imaging investigation."	I	C
"In unstabled patients with a suspicion of AAS, the following imaging modalities are recommended according to local availability and expertise:
TOE"	I	C
CT	I	C
"In stable patients with a suspicion of AAS, the following imaging modalities are recommended (or should be considered) according to local availability and expertise:
CT	I	C
MRI	I	C
TOE"	IIa	C
"In case of initially negative imaging with the persistence of suspicion of AAS, repetitive imaging (CT or MRI) is recommended."	I	C
"Chest X-ray maybe considered in cases of low clinical probability of AAS."	IIb	C
"In case of uncomplicated Type B AD treated medically, repeated imaging (CT or MRI)e during the first days is recommended."	I	C

Abbreviations: AAS: acute aortic syndrome; AD: aortic dissection; CT: computed tomography; MRI: magnetic resonance imaging; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography.

References

↑ Schematic view of acute aortic syndrome by Sahar
↑ Erbel, R (2001). "Diagnosis and management of aortic dissection Task Force on Aortic Dissection, European Society of Cardiology". European Heart Journal. 22 (18): 1642–1681. doi:10.1053/euhj.2001.2782. ISSN 0195-668X.
↑ "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases". European Heart Journal. 35 (41): 2873–2926. 2014. doi:10.1093/eurheartj/ehu281. ISSN 0195-668X.
↑ Smith AD, Schoenhagen P (January 2008). "CT imaging for acute aortic syndrome". Cleve Clin J Med. 75 (1): 7–9, 12, 15–7 passim. doi:10.3949/ccjm.75.1.7. PMID 18236724.
↑ Evangelista Masip A (April 2007). "[Progress in the acute aortic syndrome]". Rev Esp Cardiol (in Spanish; Castilian). 60 (4): 428–39. doi:10.1157/13101646. PMID 17521551.
↑ Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
↑ Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.
↑ ^8.0 ^8.1 Eggebrecht, Holger; Mehta, Rajendra H.; Metozounve, Huguette; Huptas, Sebastian; Herold, Ulf; Jakob, Heinz G.; Erbel, Raimund (2008). "Clinical Implications of Systemic Inflammatory Response Syndrome Following Thoracic Aortic Stent-Graft Placement". Journal of Endovascular Therapy. 15 (2): 135–143. doi:10.1583/07-2284.1. ISSN 1526-6028.
↑ ^9.0 ^9.1 Sutherland, Alexander; Escano, Jude; Coon, Troy P. (2008). "D-dimer as the Sole Screening Test for Acute Aortic Dissection: A Review of the Literature". Annals of Emergency Medicine. 52 (4): 339–343. doi:10.1016/j.annemergmed.2007.12.026. ISSN 0196-0644.
↑ Suzuki, Toru; Bossone, Eduardo; Sawaki, Daigo; Jánosi, Rolf Alexander; Erbel, Raimund; Eagle, Kim; Nagai, Ryozo (2013). "Biomarkers of aortic diseases". American Heart Journal. 165 (1): 15–25. doi:10.1016/j.ahj.2012.10.006. ISSN 0002-8703.
↑ Taylor, R. Andrew; Iyer, Neel S. (2013). "A decision analysis to determine a testing threshold for computed tomographic angiography and d-dimer in the evaluation of aortic dissection". The American Journal of Emergency Medicine. 31 (7): 1047–1055. doi:10.1016/j.ajem.2013.03.039. ISSN 0735-6757.

Template:Vascular diseases

[1] Schematic view of acute aortic syndrome by Sahar

[Erbel2001-2] Erbel, R (2001). "Diagnosis and management of aortic dissection Task Force on Aortic Dissection, European Society of Cardiology". European Heart Journal. 22 (18): 1642–1681. doi:10.1053/euhj.2001.2782. ISSN 0195-668X.

[3] "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases". European Heart Journal. 35 (41): 2873–2926. 2014. doi:10.1093/eurheartj/ehu281. ISSN 0195-668X.

[pmid18236724-4] Smith AD, Schoenhagen P (January 2008). "CT imaging for acute aortic syndrome". Cleve Clin J Med. 75 (1): 7–9, 12, 15–7 passim. doi:10.3949/ccjm.75.1.7. PMID 18236724.

[pmid17521551-5] Evangelista Masip A (April 2007). "[Progress in the acute aortic syndrome]". Rev Esp Cardiol (in Spanish; Castilian). 60 (4): 428–39. doi:10.1157/13101646. PMID 17521551.

[pmid25173340-6] Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.

[EvangelistaIsselbacher2018-7] Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.

[EggebrechtMehta2008-8] 8.0 ^8.1 Eggebrecht, Holger; Mehta, Rajendra H.; Metozounve, Huguette; Huptas, Sebastian; Herold, Ulf; Jakob, Heinz G.; Erbel, Raimund (2008). "Clinical Implications of Systemic Inflammatory Response Syndrome Following Thoracic Aortic Stent-Graft Placement". Journal of Endovascular Therapy. 15 (2): 135–143. doi:10.1583/07-2284.1. ISSN 1526-6028.

[SutherlandEscano2008-9] 9.0 ^9.1 Sutherland, Alexander; Escano, Jude; Coon, Troy P. (2008). "D-dimer as the Sole Screening Test for Acute Aortic Dissection: A Review of the Literature". Annals of Emergency Medicine. 52 (4): 339–343. doi:10.1016/j.annemergmed.2007.12.026. ISSN 0196-0644.

[SuzukiBossone2013-10] Suzuki, Toru; Bossone, Eduardo; Sawaki, Daigo; Jánosi, Rolf Alexander; Erbel, Raimund; Eagle, Kim; Nagai, Ryozo (2013). "Biomarkers of aortic diseases". American Heart Journal. 165 (1): 15–25. doi:10.1016/j.ahj.2012.10.006. ISSN 0002-8703.

[TaylorIyer2013-11] Taylor, R. Andrew; Iyer, Neel S. (2013). "A decision analysis to determine a testing threshold for computed tomographic angiography and d-dimer in the evaluation of aortic dissection". The American Journal of Emergency Medicine. 31 (7): 1047–1055. doi:10.1016/j.ajem.2013.03.039. ISSN 0735-6757.

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@@ Line 1: / Line 1: @@
 __NOTOC__
+[[File:Capture AD.PNG|right|300px|<ref>Schematic view of acute aortic syndrome by Sahar</ref>]]
 {{Acute aortic syndrome}}
-{{CMG}}{{AE}}
+{{CMG}}{{AE}} {{Sahar}}, {{Sab}}
 ==Overview==
-'''Acute aortic syndrome''' ('''AAS''') describes a range of severe, [[pain]]ful, potentially life-threatening abnormalities of the [[aorta]].<ref name="pmid16679467">{{cite journal |author=Ahmad F, Cheshire N, Hamady M |title=Acute aortic syndrome: pathology and therapeutic strategies |journal=Postgrad Med J |volume=82 |issue=967 |pages=305–12 |date=May 2006 |pmid=16679467 |doi=10.1136/pgmj.2005.043083 |url=http://pmj.bmjjournals.com/cgi/pmidlookup?view=long&pmid=16679467 |pmc=2563796}}</ref> These include [[aortic dissection]], intramural [[thrombus]], and [[penetrating atherosclerotic ulcer|penetrating atherosclerotic aortic ulcer]].<ref name="Macura">{{cite journal | last=Macura | first=KJ |author2=Corl FM|author3=Fishman EK|author4=Bluemke DA | title=Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer | journal=American Journal of Roentgenology | volume=181 | issue=2 | pages=309–316 | date=1 August 2003 | pmid=12876003 | url=http://www.ajronline.org/cgi/content/full/181/2/309 | accessdate=2008-05-28 | doi=10.2214/ajr.181.2.1810309}}</ref> AAS can be caused by a [[lesion]] on the wall of the [[aorta]] that involves the [[tunica media]], often in the [[descending aorta]].<ref name="pmid17521551">{{cite journal |author=Evangelista Masip A |title=[Progress in the acute aortic syndrome] |language=Spanish; Castilian |journal=Rev Esp Cardiol |volume=60 |issue=4 |pages=428–39 |date=April 2007 |pmid=17521551 | url=http://www.revespcardiol.org/cgi-bin/wdbcgi.exe/cardio/mrevista_cardio.pubmed_full?inctrl=05ZI0113&vol=60&num=4&pag=428 |doi=10.1157/13101646}}</ref>  It is possible for AAS to lead to [[acute coronary syndrome]].<ref name="pmid16291307">{{cite journal |author=Manghat NE, Morgan-Hughes GJ, Roobottom CA |title=Multi-detector row computed tomography: imaging in acute aortic syndrome |journal=Clin Radiol |volume=60 |issue=12 |pages=1256–67 |date=December 2005 |pmid=16291307 |doi=10.1016/j.crad.2005.06.011 |url=}}</ref>  The term was introduced in 2001.<ref name="pmid12860875">{{cite journal |author=van der Loo B, Jenni R |title=Acute aortic syndrome: proposal for a novel classification |journal=Heart |volume=89 |issue=8 |pages=928 |date=August 2003 |pmid=12860875 |doi= 10.1136/heart.89.8.928|url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=12860875 |pmc=1767786}}</ref><ref name="pmid11250953">{{cite journal |author=Vilacosta I, Román JA |title=Acute aortic syndrome |journal=Heart |volume=85 |issue=4 |pages=365–8 |date=April 2001 |pmid=11250953 |doi= 10.1136/heart.85.4.365|url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=11250953 |pmc=1729697}}</ref>
+'''Acute aortic syndrome''' ('''AAS''') describes a constellation of emergency conditions with a similar clinical feature that involves the [[aorta]]. These include [[aortic dissection]], intramural [[thrombus]], and [[penetrating atherosclerotic aortic ulcer]]. It is possible for AAS to get complicated by [[acute coronary syndrome]]. The term was introduced in 2001.
-<!--==Classification==-->
-<!-- ==Signs and symptoms== -->
-==Causes==
+==Classification==
-Causes can include [[aortic dissection]], [[intramural hematoma]], [[penetrating atherosclerotic ulcer]] or a [[thoracic aneurysm]] that has become unstable.<ref name="pmid18236724">{{cite journal |author=Smith AD, Schoenhagen P |title=CT imaging for acute aortic syndrome |journal=Cleve Clin J Med |volume=75 |issue=1 |pages=7–9, 12, 15–7 passim |date=January 2008 |pmid=18236724 |doi= 10.3949/ccjm.75.1.7|url=}}</ref>  The potential causes of AAS are life-threatening and present with similar symptoms, making it difficult to distinguish the ultimate cause, though high resolution, high contrast [[computerised tomography]] can be used.<ref name="pmid18236724"/><ref name="pmid17612751">{{cite journal |author=Marijon E, Vilanculos A, Tivane A, ''et al.'' |title=Thoracic aortic aneurysm: direct sign of rupture |journal=Cardiovasc J Afr |volume=18 |issue=3 |pages=180–1 |year=2007 |pmid=17612751 |doi= | format = pdf |url=http://blues.sabinet.co.za/WebZ/Authorize?sessionid=0:autho=pubmed:password=pubmed2004&/AdvancedQuery?&format=F&next=images/ejour/cardio/cardio_v18_n3_a10.pdf}}</ref>
+Acute aortic syndrome is [[Classification|classified]] into 5 entities as follows:<ref name="Erbel2001">{{cite journal|last1=Erbel|first1=R|title=Diagnosis and management of aortic dissection Task Force on Aortic Dissection, European Society of Cardiology|journal=European Heart Journal|volume=22|issue=18|year=2001|pages=1642–1681|issn=0195668X|doi=10.1053/euhj.2001.2782}}</ref><ref>{{cite journal|title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases|journal=European Heart Journal|volume=35|issue=41|year=2014|pages=2873–2926|issn=0195-668X|doi=10.1093/eurheartj/ehu281}}</ref>
+* Type I: classic aortic dissection involving an [[intimal]] layer between the true and false lumen (with no communication between the two lumen)
+* Type II: aortic dissection with medial rupture and the subsequent [[intramural]] [[hematoma]] formation
+* Type III: subtle aortic dissection with bulging of the aortic wall
+* Type IV: aortic dissection due to [[plaque rupture]] and subsequent [[ulceration]]
+* Type V: [[iatrogenic]]/traumatic dissection
-<!-- ==Pathophysiology== -->
+==Differentiating Acute Aortic Syndrome from other Diseases==
-== Diagnosis ==
+*Acute aortic syndrome should be differentiated from other [[conditions]] causing [[signs]] and [[symptoms]] such as [[chest pain]], [[dyspnea]], [[back pain]] and etc.
-The condition can be mimicked by a ruptured [[cyst]] of the [[pericardium]],<ref name="pmid18296680">{{cite journal |author=Nishigami K, Hirayama T, Kamio T |title=Pericardial cyst rupture mimicking acute aortic syndrome |journal=Eur. Heart J. |volume= 29|issue= 14|pages= 1752|date=February 2008 |pmid=18296680 |doi=10.1093/eurheartj/ehn038 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18296680}}</ref> ruptured [[aortic aneurysm]]<ref name="pmid17612751"/> and [[acute coronary syndrome]].<ref name="pmid17350381">{{cite journal |author=Hansen MS, Nogareda GJ, Hutchison SJ |title=Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection |journal=Am. J. Cardiol. |volume=99 |issue=6 |pages=852–6 |date=March 2007 |pmid=17350381 |doi=10.1016/j.amjcard.2006.10.055 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(06)02407-6}}</ref>
+*For more information on the [[differential diagnosis]] of the acute aortic syndrome [[Aortic dissection differential diagnosis|click here]].
-Misdiagnosis is estimated at 39% and is associated with delays correct diagnosis and improper treatment with [[anticoagulant]]s producing excessive bleeding and extended hospital stay.<ref name="pmid17350381"/>
+==Causes==
+*Causes include [[aortic dissection]], [[intramural hematoma]], [[penetrating atherosclerotic ulcer]] or a [[thoracic aneurysm]] that has become unstable.<ref name="pmid18236724">{{cite journal |author=Smith AD, Schoenhagen P |title=CT imaging for acute aortic syndrome |journal=Cleve Clin J Med |volume=75 |issue=1 |pages=7–9, 12, 15–7 passim |date=January 2008 |pmid=18236724 |doi= 10.3949/ccjm.75.1.7|url=}}</ref>
+*Basically, AAS can be caused by a breakdown on the wall of the [[aorta]] that involves the tunica intima and/or media.<ref name="pmid17521551">{{cite journal |author=Evangelista Masip A |title=[Progress in the acute aortic syndrome] |language=Spanish; Castilian |journal=Rev Esp Cardiol |volume=60 |issue=4 |pages=428–39 |date=April 2007 |pmid=17521551 | url=http://www.revespcardiol.org/cgi-bin/wdbcgi.exe/cardio/mrevista_cardio.pubmed_full?inctrl=05ZI0113&vol=60&num=4&pag=428 |doi=10.1157/13101646}}</ref>
+*For more information on [[aortic dissection]] causes [[Aortic dissection causes|click here]].
+*For more information on [[aortic intramural hematoma]] causes [[Aortic intramural hematoma|click here]].
+*For more information on [[penetrating atherosclerotic aortic ulcer]] causes [[Penetrating atherosclerotic aortic ulcer|click here]].
-<!-- ==Prevention== -->
+==Guidelines==
-==Management==
+===2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)<ref name="pmid25173340">{{cite journal |vauthors=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ |title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>===
+{| border="4"
+|+
+! style="background: #FFFF00; width: 150px;" | Recommendations !! style="background: #FFFF00; width: 150px;" | Class !! style="background: #FFFF00; width: 150px;" | Level !! style="background: #FFFF00; width: 150px;" | References
+|-
+! colspan="4"   align="left" |History and clinical assessment
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="left" |
+* <nowiki>"</nowiki>In all [[patients]] with suspected AAS, pre-test probability assessment is recommended, according to the [[Patient|patient’s]] [[condition]], [[symptoms]], and clinical features.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #0000CD;" align="center" |{{fontcolor|#FFF|B}}
+|" align="center" |<ref name="EvangelistaIsselbacher2018">{{cite journal|last1=Evangelista|first1=Arturo|last2=Isselbacher|first2=Eric M.|last3=Bossone|first3=Eduardo|last4=Gleason|first4=Thomas G.|last5=Eusanio|first5=Marco Di|last6=Sechtem|first6=Udo|last7=Ehrlich|first7=Marek P.|last8=Trimarchi|first8=Santi|last9=Braverman|first9=Alan C.|last10=Myrmel|first10=Truls|last11=Harris|first11=Kevin M.|last12=Hutchinson|first12=Stuart|last13=O’Gara|first13=Patrick|last14=Suzuki|first14=Toru|last15=Nienaber|first15=Christoph A.|last16=Eagle|first16=Kim A.|title=Insights From the International Registry of Acute Aortic Dissection|journal=Circulation|volume=137|issue=17|year=2018|pages=1846–1860|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031264}}</ref>
+|-
+! colspan="4"   align="left" | Laboratory testing
+|-
+! style="padding: 5px 5px; background: #FFFFE0; " align="left" |
+* <nowiki>"</nowiki>In case of suspicion of AAS, the interpretation of [[biomarkers]] should always be considered along with the pretest clinical probability.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #FFA500;" align="center" |'''IIa'''
+| style="padding: 5px 5px; background: #0000CD;" align="center" |{{fontcolor|#FFF|B}}
+|
+|-
+! style="padding: 5px 5px; "  align="left" |
+* <nowiki>"</nowiki>In case of low clinical probability of AAS, negative [[D-dimer]] levels should be considered as ruling out the [[diagnosis]].<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #FFA500;" align="center" |'''IIa'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+| align="center" |<ref name="EggebrechtMehta2008">{{cite journal|last1=Eggebrecht|first1=Holger|last2=Mehta|first2=Rajendra H.|last3=Metozounve|first3=Huguette|last4=Huptas|first4=Sebastian|last5=Herold|first5=Ulf|last6=Jakob|first6=Heinz G.|last7=Erbel|first7=Raimund|title=Clinical Implications of Systemic Inflammatory Response Syndrome Following Thoracic Aortic Stent-Graft Placement|journal=Journal of Endovascular Therapy|volume=15|issue=2|year=2008|pages=135–143|issn=1526-6028|doi=10.1583/07-2284.1}}</ref><ref name="SutherlandEscano2008">{{cite journal|last1=Sutherland|first1=Alexander|last2=Escano|first2=Jude|last3=Coon|first3=Troy P.|title=D-dimer as the Sole Screening Test for Acute Aortic Dissection: A Review of the Literature|journal=Annals of Emergency Medicine|volume=52|issue=4|year=2008|pages=339–343|issn=01960644|doi=10.1016/j.annemergmed.2007.12.026}}</ref><ref name="SuzukiBossone2013">{{cite journal|last1=Suzuki|first1=Toru|last2=Bossone|first2=Eduardo|last3=Sawaki|first3=Daigo|last4=Jánosi|first4=Rolf Alexander|last5=Erbel|first5=Raimund|last6=Eagle|first6=Kim|last7=Nagai|first7=Ryozo|title=Biomarkers of aortic diseases|journal=American Heart Journal|volume=165|issue=1|year=2013|pages=15–25|issn=00028703|doi=10.1016/j.ahj.2012.10.006}}</ref><ref name="TaylorIyer2013">{{cite journal|last1=Taylor|first1=R. Andrew|last2=Iyer|first2=Neel S.|title=A decision analysis to determine a testing threshold for computed tomographic angiography and d-dimer in the evaluation of aortic dissection|journal=The American Journal of Emergency Medicine|volume=31|issue=7|year=2013|pages=1047–1055|issn=07356757|doi=10.1016/j.ajem.2013.03.039}}</ref>
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="left" |
+* <nowiki>"</nowiki>In case of intermediate clinical probability of AAS with a positive (point-of-care) [[D-dimer]] test, further [[imaging]] tests should be considered.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #FFA500;" align="center" |'''IIa'''
+| style="padding: 5px 5px; background: #0000CD;" align="center" |{{fontcolor|#FFF|B}}
+| align="center" |<ref name="EggebrechtMehta2008">{{cite journal|last1=Eggebrecht|first1=Holger|last2=Mehta|first2=Rajendra H.|last3=Metozounve|first3=Huguette|last4=Huptas|first4=Sebastian|last5=Herold|first5=Ulf|last6=Jakob|first6=Heinz G.|last7=Erbel|first7=Raimund|title=Clinical Implications of Systemic Inflammatory Response Syndrome Following Thoracic Aortic Stent-Graft Placement|journal=Journal of Endovascular Therapy|volume=15|issue=2|year=2008|pages=135–143|issn=1526-6028|doi=10.1583/07-2284.1}}</ref><ref name="SutherlandEscano2008">{{cite journal|last1=Sutherland|first1=Alexander|last2=Escano|first2=Jude|last3=Coon|first3=Troy P.|title=D-dimer as the Sole Screening Test for Acute Aortic Dissection: A Review of the Literature|journal=Annals of Emergency Medicine|volume=52|issue=4|year=2008|pages=339–343|issn=01960644|doi=10.1016/j.annemergmed.2007.12.026}}</ref>
+|-
+! style="padding: 5px 5px;"  align="left" |
+* <nowiki>"</nowiki>In [[patients]] with high probability (risk score 2 or 3) of AD, testing of [[D-dimers]] is not recommended.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #F08080;" align="center" |'''III'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+|
+|-
+! colspan="4" align="left" |Imaging
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="left" |
+* <nowiki>"</nowiki>[[TTE]] is recommended as an initial [[imaging]] investigation.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+! style="padding: 5px 5px; "  align="left" |
+* <nowiki>"</nowiki>In unstabled [[patients]] with a suspicion of AAS, the following [[imaging]] modalities are recommended according to local availability and expertise:
+!
+!
+!
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="center" |TOE<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+![[CT]]
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="left" |
+* <nowiki>"</nowiki>In stable [[patients]] with a suspicion of AAS, the following [[imaging]] modalities are recommended (or should be considered) according to local availability and expertise:
+!
+!
+!
+|-
+![[CT]]
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="center" |[[MRI]]
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+!TOE<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #FFA500;" align="center" |'''IIa'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+! style="padding: 5px 5px; background: #FFFFE0; "  align="left" |
+* <nowiki>"</nowiki>In case of initially negative [[imaging]] with the persistence of suspicion of AAS, repetitive imaging ([[CT]] or [[MRI]]) is recommended.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+! style="padding: 5px 5px;"  align="left" |
+* <nowiki>"</nowiki>[[Chest X-ray]] maybe considered in cases of low clinical probability of AAS.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #FFA500;" align="center" |'''IIb'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|-
+! style="padding: 5px 5px;  background: #FFFFE0;"  align="left" |
+* <nowiki>"</nowiki>In case of uncomplicated Type B AD treated medically, repeated [[imaging]] ([[CT]] or [[MRI]])e during the first days is recommended.<nowiki>"</nowiki>
+| style="padding: 5px 5px; background: #90EE90;" align="center" |'''I'''
+| style="padding: 5px 5px; background: #6495ED;" align="center" |{{fontcolor|#FFF|C}}
+!
+|}
+<small><small>
+'''Abbreviations:''' '''AAS''': acute aortic syndrome; '''AD''': aortic dissection; '''CT''': computed tomography; '''MRI''': magnetic resonance imaging; '''TOE''': transoesophageal echocardiography; '''TTE''': transthoracic echocardiography.
+</small></small>
-AAS is life-threatening, with a high [[mortality rate]] if appearing [[Acute (medicine)|acutely]], reduced only when diagnosed early and treated by a [[Surgery|surgeon]] with considerable expertise.<ref name="pmid17521551"/> If patients survive acute presentation, within three to five years 30% will develop [[complication (medicine)|complications]] and require close follow-up.<ref name="pmid17521551"/>  Early diagnosis is essential for survival and management is challenging though greater awareness of the syndrome and improving management strategies are improving patient outcomes.<ref name="pmid17535765">{{cite journal |author=Ince H, Nienaber CA |title=[Management of acute aortic syndromes] |language=Spanish; Castilian |journal=Rev Esp Cardiol |volume=60 |issue=5 |pages=526–41 |date=May 2007 |pmid=17535765 |doi= 10.1016/S1885-5857(07)60194-7|url=http://www.revespcardiol.org/cgi-bin/wdbcgi.exe/cardio/mrevista_cardio.pubmed_full?inctrl=05ZI0113&vol=60&num=5&pag=526}}</ref>
-<!-- ==Prognosis== -->
-<!-- ==Epidemiology== -->
-<!-- ==History== -->
-<!-- ==Society and culture== -->
-<!-- ==Research directions== -->
-<!-- ==In other animals== -->
-<!-- ==See also== -->
 ==References==
 {{Reflist|2}}
 <!-- ==Further reading== -->
 <!-- ==External links== -->
 {{Vascular diseases}}
 [[Category:Diseases of the aorta]]
 [[Category:Diseases of arteries, arterioles and capillaries]]