[Acute aortic dissection]

The acute aortic dissection is a relatively rare event carrying a grave prognosis. It is the most common fatal condition involving the aorta. A high index of suspicion is mandatory because of a mortality rate of 1 to 2% per hour in the first 48 hours. A recent series from the Mayo Clinic using modern diagnostic methods showed that in 62% of the patients the initial impression of aortic dissection was correct, but in 28% this diagnosis was only made post mortem. The clinical suspicion arises from a history of sudden severe pain in the chest or the back, sometimes wandering downwards, and from certain clinical findings like aortic regurgitation, pulse deficits or neurologic manifestations such as cerebrovascular accidents or ischemic paraparesis. ST-segment elevation in the ECG is very unusual in aortic dissection and should direct the clinical focus to acute myocardial infarction. Large-bore peripheral venous access should be established, and pain control should start immediately. Hypertensive patients should be treated first with an intravenous beta-blocking agent. Vasodilators increase aortic wall stress, they should only be administered after a beta-blocking agent. Transfer to a hospital with appropriate diagnostic and surgical is mandatory.