Selective Relevant Updates in AAD

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This is my Power Point slides concerning some recent updates in Acute Aortic Dissection in conjunction with the CME topic of Acute Aortic Dissection in our department on 1st July 2008. Note: these slides are created using Keynote and converted into Power Point format; therefore the alignment that you see and some of the fonts may not look so nice as a result :(.... hope authorSTREAM will make keynote uplodad available soon.

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Relevant Updates In Aortic Dissection : 

Relevant Updates In Aortic Dissection K.S. Chew Emergency Medicine Department School of Medical Sciences Universiti Sains Malaysia

Slide 2: 

Update No. 1

Update No. 1 : 

Update No. 1 The IRAD Findings (International Registry of Acute Aortic Dissection) New Insights Into An Old Disease Case Series from Jan 1996 - Dec 1998 Hagan PG et al. The International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA 2000 Feb 16 283 897-903.

Key IRAD Findings : 

Key IRAD Findings In contrast to classic teaching, tearing or ripping were not the characteristic descriptors of pain. More patients described the chest pain as sharp in nature (64.4%), rather than tearing (50.6%)

Key IRAD Findings : 

Key IRAD Findings Pulse deficit is a classical finding, but it is not common (15.1%) Widening mediastinum is present on chest X-ray in 61.6%; more than 1/5th (21.1%) has a normal looking CXR. ECG was normal in 31.3% of patients.

Conclusion : 

Conclusion Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. A normal CXR or ECG does not exclude acute aortic dissection

Slide 7: 

Update No. 2

Slide 8: 

Which one carries the highest mortality?

Update No. 2 : 

Update No. 2 Post-discharge mortality of Type B dissection is still high; overall mortality 25% This is especially so for the partial thrombosis of the false lumen group Tsai TT et al. for the International Registry of Acute Aortic Dissection. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007 Jul 26; 357:349-59.

Slide 10: 

The highest risk for death was found in patients with partial thrombosis of the lumen, compared with a patent false lumen (hazard ratio, 2.7; 95% confidence interval, 1.45–4.98)

Possible Explanation : 

Possible Explanation Patent false lumen - perfused by a proximal entry tear and decompressed through distal reentry tears

Possible Explanation : 

Possible Explanation Partial thrombus - occlude these distal tears, impede outflow, significant increase in the MAP, re-dissection and rupture

Possible Explanation : 

Possible Explanation Complete thrombosis of the false lumen - excludes the false lumen from the circulation, thought to be a prerequisite for complete healing

Slide 14: 

Update No. 3

Update No. 3 : 

Update No. 3 Is there a biomarker for Acute Aortic Dissection?

D-dimers in Acute AD? : 

D-dimers in Acute AD? Weber T, et al. 2003 All patients with AAD had an elevated D-dimer leve Perez A, et al. 2004 D-dimer assay tested positive AAD Small study; retrospective. Eggebrecht H, et al. 2004 D-dimers are highly elevated in both acute PE and acute AD

D-dimers : 

D-dimers A systematic literature review and meta-analysis Objective: to determine diagnostic D-dimer cutoff values for AAD then to validate the findings in a cohort of 65 patients with confirmed AAD who presented to a single institution in Austria during a 4-year period.

Results : 

Results Mean NPV is 100% for a cut-off level of 0.1 µg/mL in our study population. 99% for 0.5 µg/mL (the value often used for exclusion of pulmonary embolism) 92% for 0.9 µg/mL A D-dimer <0.1 µg/mL will exclude AAD in all cases.

Conclusion : 

Conclusion An elevated D-dimer level will always be a nonspecific finding, and no importance should be given to the reported positive predictive value. In patients with low-to-intermediate suspicion for AAD, the D-dimer assay might prove to be useful in excluding the disease.

Slide 20: 

References

References : 

References Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos y Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM, Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease. JAMA. 2000 February 16, 2000;283(7):897-903.

References : 

References Tsai TT, Evangelista A, Nienaber CA, Myrmel T, Meinhardt G, Cooper JV, Smith DE, Suzuki T, Fattori R, Llovet A, Froehlich J, Hutchison S, Distante A, Sundt T, Beckman J, Januzzi JL, Jr., Isselbacher EM, Eagle KA, the International Registry of Acute Aortic D. Partial Thrombosis of the False Lumen in Patients with Acute Type B Aortic Dissection. N Engl J Med. 2007 July 26, 2007;357(4):349-59.

References : 

References Eggebrecht H, Naber CK, Bruch C, Kroger K, von Birgelen C, Schmermund A, Wichert M, Bartel T, Mann K, Erbel R. Value of plasma fibrin D-dimers for detection of acute aortic dissection. J Am Coll Cardiol. 2004 August 18, 2004;44(4):804-9.

Appendix : 

Appendix