Aortic dissection is a complex cardiac problem and a killer disease .Even though it is a fancier to make a diagnosis of aortic dissection in any intractable chest (or back )pain the most common error committed by physicians is failure to recognise it .
Is it possible to diagnose or atleast suspect aortic dissection by a rapid screening biochemical test ?
Yes, it seems so,
- D Dimer , a product released consequent to intravascular thrombosis is elevated by >500ng in most of the patients with dissection.
- Aortic smooth muscle heavy chain estimation is the other option.
Read this original article by Patrick Ohlmaan
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http://www.medscape.com/viewarticle/530783_print Courtesy Medscape
What happens once a diagnosis of aortic dissection is made ?
It is not a great achievement to make a diagnosis of aortic dissection.It is only, a beginning of a long and often tedious decision making process . A real tough task , on hand for the cardiothoracic surgeons. It is a team work , needs the interaction of cardiologists, radiologists and cardiac surgeons to bring an optimal outcome.
The major issues are
- Never try to manage this problem in a small hospital or facility. Always send the patient to a teaching hospital ( of course , not all teaching hospital can tackle this either , so enquire about their expertise ! )
- No credits for making a simple diagnosis of dissection.One has to exactly locate the entry point and exit points if any.
- Aortic root and arch involvement is of major importance in determining the modality of therapy.
- Debaky classification is not of academic interest ! it has a purpose . Generally type A dissection(Proximal ) require emergency surgery
- Differentiating true lumen from false lumen is of critical importance , it needs a meticulous transesophageal echocardiogram.( Some times one may , never be sure which is true and which is false lumen , funnily .in descending aortic dissection it may never matter for the patient !) Self healing of many dissections with thrombus is possible.
- Controlling hypertension with powerful parentral antihypertenive drugs (Labetalol . . . ideally ) is vital.
- Side branch involvement (spiral dissections) especially arch vessels and renal arteries make this entity much more complex
- Isolated distal dissections and some low risk proximal dissections can indeed be managed conservatively(Also called non surgical ! ) Some cardiologists or even institutions hesitate to put a aortic dissection with medical management .They feel it is inferior form of treatment . . . but realise , it is not necessarily so !)
What is the other bichemical marker for disscetion ?
The aortic smooth Muscle Myosin Heavy Chain was proposed as a useful marker for diagnoisng dissection.
Diagnostic Implications of Elevated Levels of Smooth-Muscle Myosin Heavy-Chain Protein in Acute Aortic Dissection: The Smooth Muscle Myosin Heavy Chain Study Toru Suzuki, MD; Hirohisa Katoh, PhD; Yasuhiro Tsuchio, MD; Annals of internal medicine 3 October 2000 | Volume 133 Issue 7 | Pages 537-541
The abstract from annlas of internal medicine follows Readers from India can get the full text article free
- http://www.annals.org/cgi/content/abstract/133/7/537
- http://www.annals.org/cgi/content/full/133/7/537
Dr.S.Venkatesan MD 