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Aortic dissection

Updated Oct 15, 2026Adults · ED management7 sources · 3 checked in PubMed3 figuresACC/AHA 2022 guideline

Bottom line

  • Score it. ADD-RS counts how many of three categories are present: predisposing conditions, high-risk pain, high-risk exam findings (0–3).5
  • ADD-RS 2–3: go straight to CT angiography. ADD-RS 0–1: a D-dimer under 500 ng/mL makes dissection unlikely, but the combined pathway is not yet externally validated.3,5
  • Rate first, then pressure. IV beta-blocker to a heart rate of 60–80 and systolic BP under 120 (or the lowest that keeps organs perfused). Add a vasodilator only if BP stays high.2
  • Type A is a surgical emergency. Call cardiac surgery immediately (Class 1). Stable patients may do better transferred to a high-volume aortic center (Class 2a).1
  • Uncomplicated type B is medical. Intervene for rupture, malperfusion, extension, enlargement, intractable pain or uncontrolled hypertension.2

Recognize: ADD-RS

Category (1 point if any present)Features
High-risk conditionsMarfan or other connective tissue disease; family history of aortic disease; known aortic valve disease; recent aortic manipulation; known thoracic aortic aneurysm
High-risk painChest, back or abdominal pain that is abrupt and/or severe, and tearing, ripping or sharp
High-risk examPulse deficit, systolic BP differential, or focal neurological deficit (with pain); new aortic regurgitation murmur (with pain); hypotension or shock

The score is the number of categories present, not the number of features. A score of 0 lowers the probability substantially but does not exclude dissection.5

Ruling out

  1. ADD-RS 2–3: proceed directly to CT angiography or other definitive imaging.5
  2. ADD-RS 0–1: check a D-dimer. Under 500 ng/mL, consider stopping the dissection workup. At or above 500, image.5

What ADvISED showed (1,850 patients)

  • 13% had an acute aortic syndrome. D-dimer was 96.7% sensitive and 64% specific.3
  • ADD-RS ≤ 1 with negative D-dimer: 3 missed cases in 924 patients (0.3% failure). This applied to about half of all patients.3
  • ADD-RS 0 with negative D-dimer: 1 missed case in 294 (0.3%), applying to 16% of patients.3
Use with caution

ADD-RS itself is validated, but the combined ADD-RS plus D-dimer algorithm has not been externally validated for ruling out dissection.5 It guides imaging; it does not diagnose.5

Imaging and classification

CT has become the main diagnostic test. In over 7,300 registry patients from more than 51 sites in 12 countries, CT use rose over 20 years, along with surgery for type A and endovascular repair for type B.4

Diagram of three aortas: DeBakey I and II grouped as Stanford A involving the ascending aorta, DeBakey III as Stanford B starting beyond the left subclavian artery
FIG 1Stanford and DeBakey classification. Stanford A involves the ascending aorta (DeBakey I and II). Stanford B spares it (DeBakey III). Stanford type drives the treatment decision.Vanda Machová, MD · Wikimedia Commons · CC BY 3.0
Axial contrast CT of the chest with arrows on dissection flaps in the ascending and descending aorta
FIG 2Type A dissection on CT. Intimal flaps (arrows) in both the ascending and the descending aorta.James Heilman, MD · Wikimedia Commons · CC BY-SA 3.0
Axial contrast CT with an arrow on a curved intimal flap inside a dilated ascending aorta
FIG 3Ascending aortic flap. A thin intimal flap (arrow) divides the ascending aorta into true and false lumens.James Heilman, MD · Wikimedia Commons · CC BY-SA 3.0

Initial management

GoalTarget or action
Heart rate60–80 bpm
Systolic BP< 120 mm Hg, or the lowest that maintains end-organ perfusion
First lineIV beta-blocker, unless contraindicated
BP still highAdd a vasodilator after the beta-blocker
PainTreat it; pain control is part of initial therapy

Targets from the ACC summary of the 2022 ACC/AHA guideline.2 The guideline frames immediate medical therapy as aggressive heart rate and blood pressure control plus pain control, alongside surgical evaluation.1

  • Labetalol (label): 20 mg slow IV over 2 minutes, then 40–80 mg every 10 minutes as needed, up to 300 mg total. A continuous infusion is the alternative.6
  • Esmolol is a short-acting, titratable IV option. Dose per your institutional protocol and the product label.

Type A

  • Emergency surgical consultation and immediate repair when type A is suspected or confirmed (Class 1).1
  • Malperfusion of the kidneys, gut or legs: immediate operative repair.2
  • Transfer: for clinically stable patients, transfer from a low-volume to a high-volume aortic center is reasonable to improve survival (Class 2a).1
  • Type A intramural hematoma: prompt surgical repair, even if uncomplicated.2

Type B

  • Uncomplicated: medical therapy first.2
  • Complicated, intervene for: rupture, branch-artery occlusion with malperfusion, extension of the dissection, progressive aortic enlargement, intractable pain, or uncontrolled hypertension.2
  • Rupture with suitable anatomy: endovascular stent-graft over open repair.2
  • Type B intramural hematoma: medical therapy if uncomplicated; urgent repair with malperfusion, periaortic hematoma, tamponade, refractory pain or rupture.2
  • Penetrating aortic ulcer: urgent repair with rupture, or in the ascending aorta with hematoma; repair if pain persists.2

Disposition and follow-up

  • Type A: operating room, or transfer to a high-volume aortic center if stable.1
  • Type B and intramural hematoma: admit for blood pressure and heart rate control and serial imaging.2
  • After any acute aortic syndrome: long-term beta-blockers, and CT or MRI at 1, 6 and 12 months, then yearly if stable.2

Pitfalls

  • Starting a vasodilator before the beta-blocker.2
  • Using a D-dimer to rule out dissection when ADD-RS is 2–3.5
  • Treating ADD-RS 0 alone as a rule-out.5
  • Delaying the surgical call for a suspected type A while workup continues.1
  • Missing malperfusion: check pulses, neurology, gut and kidneys, since malperfusion changes the timing of repair.2

How strong is the evidence?

Management recommendations come from the 2022 ACC/AHA guideline, largely based on registry and observational data.1,4 The guideline's full text was not retrievable for this draft, so targets come from the ACC's official summary and quoted guideline statements; each is cited.1,2 The rule-out pathway rests on one large prospective study.3 For podcast-style review, see Emergency Medicine Cases.7

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

Q1How is the ADD-RS scored?
Count the categories present, not the individual features: high-risk conditions, high-risk pain, high-risk exam findings. The score runs 0–3.5
Q2ADD-RS is 1 and the D-dimer is 320 ng/mL. What next?
Consider stopping the dissection workup.5 In ADvISED, ADD-RS ≤ 1 with a negative D-dimer missed 0.3%, but the combined pathway has not been externally validated, so use clinical judgment.3,5
Q3What are the heart rate and blood pressure targets, and which drug goes first?
Heart rate 60–80 and systolic BP under 120, or the lowest that keeps organs perfused. Start an IV beta-blocker; add a vasodilator only if BP stays high.2
Q4What separates Stanford A from B, and why does it matter?
Type A involves the ascending aorta and needs emergency surgery (Class 1).1 Type B spares it; uncomplicated type B is treated medically.2
Q5What makes a type B dissection "complicated"?
Rupture, branch-artery occlusion with malperfusion, extension, progressive enlargement, intractable pain, or uncontrolled hypertension.2
Q6A stable type A arrives at a hospital without aortic surgery. What's the move?
Transfer to a high-volume aortic center is reasonable to improve survival (Class 2a), alongside immediate surgical consultation.1

References

  1. 1
    Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation. 2022;146(24):e334–e482.GuidelinePMID 36322642PMCPubMed record; full text blocked to automated access
  2. 2
    American College of Cardiology. 2022 ACC/AHA Aortic Disease Guideline Key Perspectives: Part 2 of 2.Summaryacc.orgPage read
  3. 3
    Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation. 2018;137(3):250–258.Diagnostic studyPMID 29030346PubMed
  4. 4
    Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation. 2018;137(17):1846–1860.RegistryPMID 29685932PubMed
  5. 5
    Rogers J, Hayes J. Aortic Dissection Detection Risk Score (ADD-RS). Life in the Fast Lane; June 12, 2025.FOAMlitfl.comPage read
  6. 6
    Labetalol hydrochloride injection prescribing information (Hospira). DailyMed, US National Library of Medicine.Drug labelDailyMedLabel text read
  7. 7
    Emergency Medicine Cases. Aortic dissection. Further reading; not used for any claim above.FOAMemergencymedicinecases.comLink checked
How this page was made
  • Written from scratch. No source text was copied; facts are restated and cited.
  • The 2022 guideline's full text was blocked to automated access. Targets and type B criteria come from the ACC's official summary; Class 1 and 2a statements come from quoted guideline text. Each is cited.
  • Trial and registry results were checked against PubMed abstracts. The labetalol dose comes from the FDA label. The esmolol dose could not be confirmed from the label text, so none is given.
  • Figures 1–3 are openly licensed images from Wikimedia Commons, credited under each one, and keep their own licenses.
  • Not for clinical use until physician review.
Not for clinical use

AI-generated draft. Not reviewed by a physician. This page is for education only and may contain errors, including in doses. Do not use it to diagnose, treat or make decisions about any patient. Rely on your own clinical judgment, your institution's protocols and current drug labeling. Reading this page does not create a physician-patient relationship. Full terms