Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected acute nontraumatic thoracic aortic dissection. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected acute nontraumatic thoracic aortic dissection, are there clinical decision rules that identify a group of patients at very low risk for the diagnosis of thoracic aortic dissection? (2) In adult patients with suspected acute nontraumatic thoracic aortic dissection, is a negative serum D-dimer sufficient to identify a group of patients at very low risk for the diagnosis of thoracic aortic dissection? (3) In adult patients with suspected acute nontraumatic thoracic aortic dissection, is the diagnostic accuracy of a computed tomography angiogram at least equivalent to transesophageal echocardiogram or magnetic resonance angiogram to exclude the diagnosis of thoracic aortic dissection? (4) In adult patients with suspected acute nontraumatic thoracic aortic dissection, does an abnormal bedside transthoracic echocardiogram establish the diagnosis of thoracic aortic dissection? (5) In adult patients with acute nontraumatic thoracic aortic dissection, does targeted heart rate and blood pressure lowering reduce morbidity or mortality? Evidence was graded and recommendations were made based on the strength of the available data.