Suspected Acute Aortic Syndrome (Adult)
Abrupt severe chest, back or abdominal pain. Covers aortic dissection and intramural haematoma.
All Pathways
Vascular SurgeryEmergency
Acute Aortic Dissection Management (ESC 2024)
Acute Aortic Dissection Management (ESC 2024): Suspected Acute Aortic Syndrome (Adult) → Recognise and Score Risk (ADD-RS) → Suspected Dissection: No Th...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Action Recognise and Score Risk (ADD-RS)
Score 1 point for each group present (0-3). ADD-RS 2 or more = high risk.
- High-risk condition: Marfan syndrome, family history of aortic disease, known aortic valve disease, known aortic aneurysm, recent aortic manipulation
- High-risk pain: chest, back or abdominal pain that is abrupt, severe, or ripping or tearing
- High-risk examination: hypotension or shock, pulse deficit or SBP difference between arms, focal neurological deficit, new aortic regurgitation murmur
- Measure BP in both arms; use the arm with the higher reading
03Warning Suspected Dissection: No Thrombolysis
Dissection can mimic STEMI or stroke. Image the aorta before any thrombolysis or antithrombotic loading. ADD-RS below 2 with STEMI on the ECG: follow the STEMI pathway.
- Thrombolysis is contraindicated in thoracic aortic dissection
- Do not start heparin or antiplatelet loading until dissection is excluded, unless the treating specialist decides
- Chest pain with new AR murmur, pulse deficit or neuro deficit: think dissection first
04Warning Hypotension or Shock: No Beta-Blocker or Vasodilator
Hypotension or shock (tamponade, rupture, severe acute aortic regurgitation, coronary malperfusion). Resuscitate and call cardiothoracic surgery now.
- Bedside TTE now (tamponade, AR, flap); TOE if too unstable for CT
- Tamponade: go straight to theatre. Pericardial drainage only as a bridge in arrest or extremis: small, controlled volumes
- No cardiac surgery on site: call the aortic centre and retrieval service at once
05Warning Not Shocked: Check Before Anti-Impulse Therapy
Pregnancy: obstetric and aortic teams; labetalol is the usual beta-blocker.
- Beta-blocker contraindicated (e.g. severe asthma): IV verapamil for rate control
- Bradycardia, heart block, decompensated heart failure or severe acute aortic regurgitation: no rate-control drug (no beta-blocker, no verapamil); urgent specialist advice
- Malperfusion, spinal cord ischaemia or brain injury: accept a higher BP (MAP) to keep perfusion
06Action Not Shocked: Anti-Impulse Therapy
ADD-RS 2 or more, or AAS confirmed: start now. ADD-RS below 2: analgesia and finish the work-up first. Target heart rate 60 b.p.m. or less and SBP <120 mmHg (lowest BP that keeps organ perfusion).
- First: IV beta-blocker (labetalol or esmolol) to heart rate 60 b.p.m. or less
- Then, only if SBP is still 120 mmHg or more: add IV vasodilator (GTN or nitroprusside; clevidipine where stocked)
- Never start a vasodilator before rate control (reflex tachycardia)
- IV opioid analgesia
- Arterial line in the arm with the higher BP, ECG monitoring, ICU or resus bed
- Dose: see local protocol and product information
07Action Confirm With Imaging
ADD-RS 2 or more: ECG-gated CT angiography neck to pelvis without delay.
- Focused TTE (with contrast if feasible) during initial assessment
- Unstable or cannot go to CT: TOE
- ADD-RS below 2: ECG (exclude STEMI), chest X-ray, D-dimer, POCUS; CT if any is positive
- CMR if CT is not available
- Report: entry tear site, extent, branch involvement, rupture, pericardial effusion
08Decision Which Type? (TEM Classification)
Type A: ascending aorta involved. Type B: ascending and arch spared. Non-A non-B: arch involved, ascending spared. Intramural haematoma: manage by the same type (type A: urgent surgery).
- T: type A, type B or non-A non-B
- E: entry tear site (E0 not seen, E1 ascending, E2 arch, E3 descending)
- M: malperfusion (M0 none, M1 coronary, M2 supra-aortic, M3 spinal, visceral or iliac)
- Intramural haematoma: manage by the same type (type A: urgent surgery; type B: as type B)
- Type A
09Warning Type A: Emergency Cardiac Surgery
Without surgery, mortality is about 1-2% per hour in the first 48 h. Call cardiothoracic surgery now. On an anticoagulant or antiplatelet, or given heparin: tell surgery and anaesthesia now (reversal, blood products); do not delay surgery. Pregnant with viable fetus: caesarean delivery before aortic repair.
- No cardiac surgery on site: transfer to an aortic centre at once; do not delay for more imaging
- Malperfusion or non-haemorrhagic stroke: still immediate surgery
- Not shocked: start or continue anti-impulse therapy
10Action Type A: Surgical Repair (Aortic Team)
Replace the ascending aorta and resect the primary entry tear. See the Type A pathway for detail.
- Open distal anastomosis (Class I)
- Hemiarch unless arch tear or arch aneurysm; arch or proximal DTA tear: consider frozen elephant trunk
- Root: resuspend the valve if leaflets are normal; replace the root if root destroyed, root aneurysm or genetic aortic disease
- Persistent malperfusion after repair: angiography, percutaneous repair or TEVAR
- GERAADA score may be used to estimate 30-day mortality (Class IIa)
11Action After Open Surgery or TEVAR
ICU care. Continue heart rate and BP control, then oral beta-blocker.
- Watch for spinal cord ischaemia, stroke, bleeding and kidney injury
- After TEVAR: imaging at 1, 6 and 12 months, then yearly to 5 years
- After open surgery: CT and TTE within 6 months, CT at 12 months, then yearly if stable
12Action Long-Term Management (All Patients)
Lifelong BP control and aortic imaging. New chest or back pain: urgent imaging.
- Long-term beta-blocker unless contraindicated; add ACE inhibitor or ARB as needed (not in pregnancy)
- Medically treated: imaging yearly if stable
- After TEVAR, no complications by 5 years: CT every 2 years
- After open repair, no patent false lumen by 3 years: CT every 2-3 years
13Action Genetic Assessment
Heritable thoracic aortic disease changes treatment and family screening.
- Family history over 3 generations: aortic disease, unexplained sudden death, aneurysms
- Age 60 or less, or other risk factors for heritable disease: genetic counselling at an expert centre, then testing if indicated
- Pathogenic variant found: test at-risk relatives (cascade testing)
- Risk factors but no variant and no family history: TTE screening of first-degree relatives
14Outcome Lifelong Surveillance
Continue BP control and imaging for life. Re-intervention is common, most of all after TEVAR.
- Type B
15Decision Type B: Complicated?
Complicated = rupture, malperfusion, extension, aortic enlargement, refractory hypertension or pain.
- Contained or free rupture
- Organ or limb malperfusion, paraplegia
- Extension or progressive enlargement on repeat imaging
- Hypertension despite more than 3 drug classes, or pain for more than 12 h
- If Yes
16Warning Complicated Type B: Emergency Intervention
TEVAR is first-line if the anatomy is suitable (Class I). Open repair if not.
- Known or suspected heritable aortic disease (e.g. Marfan): aortic team decides; TEVAR is not first-line
- Paraplegia or spinal cord ischaemia: keep a higher MAP; spinal cord protection per aortic team
- Retrograde extension into the ascending aorta: treat as type A
17Action Complicated Type B: TEVAR
Cover the primary entry tear to restore true-lumen flow.
- Left subclavian coverage: revascularise
- Persistent malperfusion: angiography, branch stenting, or extra-anatomic bypass for the limb
- Unsuitable anatomy: open surgical repair
- Continue BP and heart rate control after the procedure
- Path rejoins step 11Shared downstream outcome
If No18Action Uncomplicated Type B: Medical Therapy
Start or continue anti-impulse therapy. Switch to oral beta-blocker after 24 h if targets are met and the gut works.
- ICU monitoring; repeat imaging during admission
- Becomes complicated: treat as complicated type B
- High-risk features: aorta >40 mm, false lumen >20-22 mm, entry tear >10 mm or on the inner curve, bloody pleural effusion, recurrent pain, readmission
- High-risk features, suitable anatomy and life expectancy >5 years: consider TEVAR at 14-90 days (Class IIa)
19Action Medically Treated Type B, Non-A Non-B or IMH: Follow-Up
CT or CMR at 1, 3, 6 and 12 months, then yearly if stable.
- Long-term oral beta-blocker unless contraindicated
- Add ACE inhibitor or ARB as needed for BP control
- New pain, growth or malperfusion: urgent aortic team review
- Path rejoins step 12Shared downstream outcome
- Non-A non-B
20Action Non-A Non-B (Arch) Dissection: Aortic Team
Arch involved, ascending aorta spared. Complicated (rupture or malperfusion): emergency repair, as for complicated type B. Medical treatment alone has high mortality.
- Anti-impulse therapy as above
- Surgery or endovascular repair is favoured within 14 days of onset
- Complicated with arch tear: consider frozen elephant trunk; stent-graft over the entry tear if feasible
- Aortic team chooses medical treatment: follow up as medically treated type B
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 19Shared downstream outcome
Guideline Source
2024 ESC Guidelines for the management of peripheral arterial and aortic diseases
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Pregnancy needs obstetric and aortic team care; see ESC 2024 Section 9.3.1.4.5.
- No doses given: use local protocol and product information. Nicardipine and IV diltiazem are not on the ARTG.
- Type A and type B detail: see the Type A and Type B aortic dissection pathways.
- Does not cover penetrating aortic ulcer, traumatic aortic injury or chronic dissection.
Contraindicated Populations
children
Applicable Regions
USEUGlobal
AU: Nicardipine and IV diltiazem are not on the ARTG. IV verapamil is the non-dihydropyridine option. Hospitals without cardiac surgery: transfer early to a cardiac surgical centre.
EU: ESC 2024 PAAD guideline; TEM classification (EACTS/STS 2024).
US: 2022 ACC/AHA aortic guideline: SBP <120 mmHg, heart rate 60-80 b.p.m.; nicardipine and clevidipine used as vasodilators.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Acute Aortic Dissection Management (ESC 2024)?
The Acute Aortic Dissection Management (ESC 2024) is a emergency clinical algorithm for Vascular Surgery. It provides a structured decision tree to guide clinical decision-making, based on 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases.
What guideline is the Acute Aortic Dissection Management (ESC 2024) based on?
This algorithm is based on 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases (DOI: 10.1093/eurheartj/ehae179).
What are the limitations of the Acute Aortic Dissection Management (ESC 2024)?
Known limitations include: Adults only. Pregnancy needs obstetric and aortic team care; see ESC 2024 Section 9.3.1.4.5.; No doses given: use local protocol and product information. Nicardipine and IV diltiazem are not on the ARTG.; Type A and type B detail: see the Type A and Type B aortic dissection pathways.; Does not cover penetrating aortic ulcer, traumatic aortic injury or chronic dissection.. Individual patient factors may require deviation from these recommendations.
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