Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- High suspicion (tearing pain, pulse/BP deficit, neuro/visceral ischemia) → place on monitor, large‑bore access, type & cross.
- Start anti‑impulse therapy: β‑blocker first (e.g., esmolol), then add nicardipine to target SBP 100–120 mmHg and HR <60.
- STAT CTA chest/abdomen/pelvis with contrast (or TEE if unstable/unavailable).
- Type A (ascending) → emergent cardiothoracic surgery (repair ± valve/coronary, manage malperfusion).
- Type B complicated (rupture, refractory pain/hypertension, malperfusion) → TEVAR after hemodynamic control; uncomplicated → optimal medical therapy with close ICU monitoring.
- Serial neuro/renal/limb checks; repeat CTA per protocol; initiate long‑term BP control and genetic screening when indicated.
Clinical Synopsis & Reasoning
Tearing chest/back pain with pulse/BP differential warrants immediate anti‑impulse therapy and CTA. Type A → emergent surgery; Type B complicated → TEVAR/branch-first strategies; all receive strict BP/HR control, analgesia, and intensive monitoring.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| ECG/troponin | Exclude ACS mimic | Often normal or nonspecific | Do not anchor on troponin |
| CTA chest/abdomen/pelvis with contrast | Definitive imaging | Intimal flap, true/false lumen | If unstable, TEE in OR/ICU |
| Labs incl. D‑dimer (adjunct) | Adjunctive | Elevated in many cases | Do not delay imaging |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Esmolol infusion | β‑blocker | Minutes | First‑line anti‑impulse (HR <60) | Hypotension, bronchospasm |
| Labetalol IV bolus/infusion | α/β‑blocker | Minutes | Alternative/adjunct | Bradycardia, bronchospasm |
| Nicardipine infusion (after β‑blockade) | DHP CCB | Minutes | Titrate SBP 100–120 mmHg | Avoid reflex tachycardia |
| Opioid analgesia (e.g., fentanyl) | Analgesic | Immediate | Pain control ↓ catecholamines | Respiratory depression |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.