Snapshot A 55-year-old man presents to the emergency department with chest pain. He describes the pain as excruciating and knife-like that began earlier in the morning. His pain is restricted to the anterior chest. Medical history is significant for hypertension, for which he is taking lisinopril. Physical examination is significant for unequal blood pressures in the arm and a diastolic murmur in the left sternal border. An electrocardiogram is unremarkable, his cardiac troponins are not elevated, and a chest radiograph demonstrates a widened mediastinum. Preparations are made to obtain a CT angiography. Introduction Clinical definition a separation of the media laminal planes, resulting in a blood-filled space in the aortic wall there are two types of aortic dissection Stanford A type a dissection involving the ascending aorta Stanford B type a dissection involving only the descending aorta Etiology hypertension (most common) connective tissue disease iatrogenic (e.g., coronary catheterization) Pathogenesis an intimal tear of the aorta causes an intramural aortic hemorrhage that separates the intima from the media the resulting hematoma may rupture through the adventitia, leading to a thoracic or abdominal cavity hemorrhage or cardiac tamponade Associated conditions Marfan syndrome bicuspid aortic valve Prognosis Stanford type A effective blood pressure control and surgical treatment improves mortality Stanford type B effective conservative or surgical treatment improves mortality Presentation Symptoms acute chest or back pain (most common) classically anterior chest pain that radiates to the back between the scapulae Physical exam unequal blood pressures in the arms weak or absent pulses diastolic decrescendo murmur when the aortic valve is involved resulting in aortic regurgitation Imaging Radiography of the chest indication to rule out other causes of chest pain (e.g., pneumothorax) finding widened mediastinum CT angiography of the chest indication most accurate imaging test for aortic dissection Differential Myocardial infarction differentiating factors an electrocardiogram may be present (e.g., ST-segment elevation) increased cardiac biomarkers Treatment Medical β-blockers indication Stanford type B aortic dissection Surgical vascular surgery indication Stanford type A aortic dissection Complications End-organ damage secondary to poor perfusion Aneurysm rupture
QUESTIONS 1 of 3 1 2 3 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.CV.13.61) A 25-year-old male presents for a new primary-care visit. He has never been seen by a physician and reports that he has been in good health. You note a very tall, very thin male whose arm span is greater than his height. The patient reports that his father had a similar build but passed away suddenly in his 40s. You suspect a genetic disorder characterized by a defect in fibrillin-1. What is the histopathology of the most common large-artery complication of this disease? QID: 100577 Type & Select Correct Answer 1 Focal granulomatous inflammation with mural lymphocytes, macrophages, giant cells 6% (9/149) 2 Eosinophilic vasculitis 4% (6/149) 3 Predominant neutrophilic infiltration with fibrinoid necrosis 6% (9/149) 4 Fibrinoid necrosis of blood vessel walls, endothelial swelling, and neutrophilic infiltrate in skin lesions 18% (27/149) 5 Cystic medial degeneration 62% (93/149) M 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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