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Cardiovascular Medicine Thoracic Aortic Aneurysm and Dissection Screening First degree relatives ofpatients with a bicuspid aortic valve should undergo noninvasive screening. First-degree relatives of patients with a mutant gene associated with aortic aneurysm and/or dissection should undergo genetic counseling and screen ing. Those with the identified genetic mutation should then undergo noninvasive aortic imaging. Diagnosis Most are discovered incidentally. Symptomatic aortic aneurysms may present with compressive symptoms such as hoarseness, dysphagia, recurrent pneumonia, and SVC syndrome. Aortic dissection symptoms include tearing chest and back pain. Physical examination findings may include new AR, HFl, and a BP differential between the arms. A widened mediastinum is seen on chest radiograph. Patients may also have evidence of thromboembolism, dissection of branch arteries (stroke, MI), or cardiac tamponade. A low D-dimer level (<0.5 pg/ml) helps rule out an acute aortic syndrome. Dissections involving the ascending aorta are classifled as type A, and all other dissections are classifled as type B. The diagnosis is established by TEE, CTA, or MRA. Bedside TEE is used for critically ill patients who cannot be moved. CTA is generally preferred for patients with acute aortic syndromes. TESTYOURSELF A 50 year-old man is evaluated for severe chest pain and left hemiparesis. ANSWER: For diagnosis, choose aortic dissection with involvement of the right carotid artery. Treatment Medical therapy for asymptomatic aortic aneurysm includes lowering BP to <130/80 mm Hg; B-blockers are the preferred anti- hypertensive agent. In patients with Marfan syndrome, p-blockers and losartan reduce the rate of aneurysm growth. Surgery is recommended when any of the following is present: o aortic diameter >5.5 cm (+.0-5.0 cm for Marfan syndrome) o aortic diameter >4.5 cm and undergoing other heart surgery . rapid growth >0.5 cm/year For acute dissection: . SBP to <120 mm Hg in first hour . IV 0 blockertherapy + nitroprusside r pain control with opioids Emergent surgery: . cardiogenic shock . type A dissection . type A intramural hematoma Uncomplicated type B dissection is treated with continued medical therapy alone, except in patients with complications, including end-organ ischemia. 42