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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

In differentiating the various etiologies of acute chest pain syndromes, the clinician is faced with identifying life-threatening situations. This article has presented a diagnostic approach for establishing the cardiovascular and noncardiovascular etiologies of acute chest pain syndromes. Cardiovascular etiologies must be identified early upon presentation in order to minimize morbidity and mortality. Myocardial ischemia and particularly necrosis is time dependent: early intervention preserves myocardium, particularly when initiating thrombolytic therapy. Aortic valvular disease, particularly critical aortic stenosis, if unrecognized, can precipitate rapid patient deterioration if inappropriately treated with nitrate therapy for presumed ischemic disease. Aortic dissection, if not properly diagnosed, can progress to stroke, MI, paralysis, and death. Noncardiovascular etiologies are similarly complex but often have less potential for life-threatening consequences. In identifying gastrointestinal bleeding, a careful rectal exam may be safely performed even in the setting of MI. A tension pneumothorax can suddenly compromise vascular return and progress to sudden death if unrecognized. Finally, chest wall symptoms, though seldom life-threatening, can be debilitating to the patient and often respond to anti-inflammatory therapy. In conclusion, the goals of this article were to present a step-wise approach to the diagnosis and management of an often complex presentation. By systematically approaching these patients with a thorough understanding of etiologies, diagnostic options, and therapeutic considerations, both physician anxiety as well as patient complications will be greatly diminished.
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PMID:Management of acute chest pain syndrome. 267 88

Aortic dissection with no entry or false lumen flow was recently identified as intramural hemorrhage of the aortic wall (IMH). Analysis of the literature revealed 209 cases of in vivo diagnosed IMH reflecting 17% of all dissections, whereas in postmortem studies this condition is found in 4-13%. Transesophageal echocardiography, computed tomography, magnetic resonance imaging and aortography (to rule out dissection) have been applied for diagnosing IMH in 57, 49, 43 and 38% of the cases, respectively. However, diagnostic accuracy of each modality is not available to date. In 34%, IMH involves the ascending aorta (type A). The average age of patients with IMH ranges between 55 and 65 years; 65% are males. In 12%, IMH was associated with abdominal aortic aneurysm. With 87%, arterial hypertension is the predominant risk factor for IMH irrespective of its location. As suggested by the term "mediastinal apoplexy" IMH may--similar to cerebral apoplexy--result from hypertensive rupture of the vasa vasorum in the aortic media. With 97%, the majority of patients present with acute chest or back pain similar to classic dissection. Mediastinal widening is found in 83%; signs of hemothorax/pleural effusion are present in 38%, acute aortic regurgitation in 26%, pericardial effusion in 23%, acute neurologic deficits in 12%, and pulse deficits in 5%. In 18%, IMH progresses to dissection and in another 15% to rupture. In 25% and 28%, respectively, dissection and rupture occur in the ascending aorta and in 12% and 9%, respectively, in the descending thoracic aorta. The 30-day mortality of IMH is 24% (36% with type A and 12% with type B IMH; p < 0.05). With surgical repair, mortality of type A IMH is lowered to 18% compared to 60% with medical treatment (p < 0.01). In contrast, with 8% mortality associated with medical treatment, prognosis of type B IMH is more favorable without surgical intervention, the latter associated with a 30-day mortality of 33% (p < 0.05). Thus, IMH is a potential precursor of dissection and should be managed like dissection with undelayed surgical intervention in patients with type A IMH and with medical treatment in type B IMH.
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PMID:[Intramural hemorrhage of the thoracic aorta: diagnosis, therapy and prognosis of 209 in vivo diagnosed cases]. 985 55

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.
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PMID:Aortic dissection: a dreaded disease with many faces. 1537 42

Aortic dissection is a life-threatening medical emergency. While an abrupt, tearing pain in the chest or back is present in more than 90% of the patients, diagnosis of aortic dissection has been shown to be particularly difficult when such symptoms are not present. In this report we describe a 36-year-old man presenting with a 10-day history of new onset of hoarseness associated with several transient headache episodes. The possibility of aortic dissection was overlooked at the initial presentation, and unilateral vocal cord palsy due to a cerebrovascular accident was the initial diagnosis. The patient's abnormal chest radiograph led to a re-diagnosis, and a Standford type-B aortic dissection was confirmed using thoracic computed tomography. The unusual presentation of aortic dissection is emphasized, and its management is discussed.
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PMID:Hoarseness as an unusual initial presentation of aortic dissection. 1582 7

Aortitis is the most serious location of the disease giant cell (temporal) arteritis (GCA). Aortic dissection or the rupture of an aortic aneurysm can be responsible for sudden death among patients with GCA. This report discusses two cases of GCA presenting with aortic dissection. One case had histologically proven giant cell aortitis. The second case was a fatal aortic dissection preceded by a stroke. We describe the main features of aortic dissection and aortitis during GCA, reviewing the existing literature on this subject, and focusing on the requirement of prospective aortic imaging studies to screen patients with this kind of location.
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PMID:Giant cell arteritis presenting with aortic dissection: two cases and review of the literature. 1676 72

Aortic dissection masquerading as ischemic stroke is particularly challenging in the era of thrombolysis as a result of narrow diagnostic time window and severe hemorrhagic potential. We describe a case of a 77-year-old patient with a presumed ischemic cerebral infarct, in whom planned treatment with tissue plasminogen activator therapy (TPA) was withheld because of partial spontaneous improvement in his condition. Shortly afterwards, newly elicited clues in the medical history and physical examination led to timely diagnosis and treatment of ascending thoracic aorta dissection, which was the underlying disorder. Analysis of the features of this case and similar previously published cases illustrates the importance of using and mastering basic diagnostic skills.
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PMID:Ischemic stroke, aortic dissection, and thrombolytic therapy--the importance of basic clinical skills. 1761 33

Aortic dissection is a disease of immediate consequence,as mortality of a proximal dissection is in excess of 50% when left untreated. Early recognition of the dissection event can lead to faster definitive correction with surgical and/or novel percutaneous approaches. Widely varying signs and symptoms can, however, make this diagnosis a challenge, further complicated by the fact that no specific imaging modality is ideal, nor immediately available, in all cases. Care must be taken inpatients where methodical evaluation is difficult,including physical exam, standard electrocardiogram and chest X-ray, before more definitive imaging. This is a case of aortic dissection that is presented as concomitant ST elevation myocardial infarction and embolic stroke, in which the patient received thrombolytics before diagnosis of the dissection itself. This arguably may have worsened her clinical course.
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PMID:Aortic dissection presenting as concomitant stroke and STEMI. 1762 90

Aortic dissection is an acute lesion of the aortic wall accompanied by separation of the media due to rupture or intramural hematoma. The incidence rate of aortic dissection is 5 to 30 cases per million people a year. Acute aortic dissection is a highly lethal cardiovascular emergency with an incidence of 2000 new cases per year in the United States and 3000 in Europe. The mortality rate of aortic dissection is 3.2/100,000 per year. In case of sudden death of nonhospitalized patients, aortic dissection was proved in 1.5% of necropsy cases. Most of patients die within 48 hours after admission or 1.4% per each hour. The main clinical manifestations of aortic dissection are acute myocardial infarction, stroke, pulmonary embolism, acute heart failure, acute pancreatitis, mesenteries thrombosis, which mislead the physician. The main measure, which might reduce the mortality, is early diagnosis of aortic dissection. The standard diagnosis is based on clinical symptoms and verification by instrumental (imaging) methods. An alternative mean for diagnosis of aortic dissection might be the determination of concentration of smooth muscle myosin heavy chain protein in blood serum, the peak of which is found after 3 hours after the onset of pain. Normal value of smooth muscle myosin heavy chain protein concentration is 2.5 microg/L, while in case of aortic dissection it exceeds 22.4 microg/L. This diagnostic method has not been introduced in Lithuania yet.
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PMID:[Aortic dissection]. 1841 93

Aortic dissection involving the arch can be complicated by extension to the supra-aortic branches. Carotid dissection may be symptomatic or asymptomatic at the time of surgery. Dissection or re-dissection of repaired carotid may happen later, with symptoms occurring days after the surgical repair, increasing the morbidity and mortality of those patients. We report a case of a patient with type A aortic dissection involving the aortic arch and extending to the supra-aortic branches. During surgery the dissection was seen extending to the distal carotid arteries with tears in the inner wall. After use of surgical glue as a sealant, seeing the persistent fragility and the presence of spiral form tears in the internal wall of the carotid arteries, intraoperative stenting of the common carotid arteries was performed using two stents to prevent carotid re-dissection and ischemic stroke in the postoperative period. In patients with aortic dissection and extension into the carotid arteries, especially with presence of tears of the inner wall, after use of a glue as a sealant of the two dissected layers, if the repaired artery wall results are still fragile, use of intraoperative carotid stenting may be of help in preventing late re-dissection.
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PMID:Type A aortic dissection involving the carotid arteries: carotid stenting during open aortic arch surgery. 1912 62

Aortic dissection is a rare and life-threatening event. While pain is the most common symptom of aortic dissection, it may be absent in ten percent of patients and present with a myriad of symptoms suggestive of a diverse range of other conditions. A high index of clinical suspicion is mandatory for the accurate and rapid diagnosis of aortic dissection. We report a 25-year-old woman with aortic dissection presenting as a posterior circulation stroke. This combination is very rare.
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PMID:Aortic dissection presenting as posterior circulation stroke. 1922 68


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