p.35 抽出テキスト
November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e402 CLINICAL STATEMENTS AND GUIDELINES Synopsis Acute aortic syndrome describes diseases involving disruptions in the aortic wall, including aortic dissection, intramural hematoma, and penetrating aortic ulcer.1 The annual incidence is 2 to 4 cases/100 000, with higher prevalence with genetic conditions that weaken the aortic wall.2 Prominent risk factors include hypertension atherosclerosis and connective tissue disease. Cocaine use may provoke dissection even without other risk factors. Acute onset of severe chest or back pain heralds acute aortic dissection in 80% to 90% of patients, sometimes characterized as ripping or tearing.3 Progression can produce end-organ hypoperfusion, and proximal extension may cause tamponade, severe acute aortic regurgitation, or rarely, STEMI. Intramural hematomas, which differ from dissection by absence of an identifiable intimal flap, have a lesser understood natural history but are typically evaluated and treated in a similar manner to dissections. Recommendation-Specific Supportive Text 1. A high index of suspicion in appropriate patients, and a coordinated, multidisciplinary evaluation is needed to optimize outcomes. The diagnostic modality of choice in stable patients is CTA, which is both highly sensitive and specific.4-6 Chest radiographs can show mediastinal widening but may be normal. 2. TTE can show pericardial effusion or aortic regurgitation, and a dissection flap can sometimes be visualized; however, more complete imaging of the aortic arch requires TEE or CT. CMR is sensitive and specific, but CT is usually more expeditious. 4.2.2 Acute Chest Pain With Suspected PE Recommendations for Acute Chest Pain With Suspected PE Referenced studies that support the recommendations are summarized in Online Data Supplement 23. COR LOE Recommendations 1 B-NR 1. In stable patients with acute chest pain with high clinical suspicion for PE, CTA using a PE protocol is recommended.1-4 1 C-EO 2. For patients with acute chest pain and possible PE, need for further testing should be guided by pretest probability. Synopsis The incidence of PE is estimated at 65 cases per 100 000, but some cases are asymptomatic and others undiagnosed.5,6 One-third of deaths are sudden, and 60% are undiagnosed before death.7 Risk factors for PE are the same for venous thromboembolism and include inherited hypercoagulable states and acquired risk factors (recent surgery, trauma, immobilization, malignancy, smoking, obesity, oral contraception). Recognition of PE can be challenging because symptoms and clinical signs may be nonspecific. Dyspnea followed by chest pain, classically pleuritic, is the most common presenting symptom.1 Signs of deep venous thrombosis may be present on examination.5 Recommendation-Specific Supportive Text 1. CTA using PE protocol is the diagnostic modality of choice in stable patients; ventilation-perfusion scanning is a second-line alternative in the acute setting.3,4 Use of clinical prediction rules to select patients for imaging can decrease radiation exposure and cost.8 Troponin (and brain natriuretic peptide) can be elevated, and echocardiography may reveal acute right ventricular strain consequent to large PEs; troponin and brain natriuretic peptide are both markers for higher mortality rate.2 2. Recognition of PE is important because prompt anticoagulation improves outcomes.2 Clinical assessment combined with pretest risk stratification can help select patients appropriate for diagnostic imaging. In the absence of shock, diagnostic evaluation depends on the clinical assessment of pretest probability.3 Several prediction rules are available that add predictive value to clinical assessment.4 D-dimers are highly sensitive but not very specific for the diagnosis of PE in ED patients. Measurement of D-dimers, using age- and sex-specific cutoffs, may be useful in patients at low to intermediate pretest probability; those with negative D-dimers can probably be discharged without further testing, whereas those with positive values should be considered for CTA.2 4.2.3 Acute Chest Pain With Suspected Myopericarditis Recommendations for Acute Chest Pain With Suspected Myopericarditis Referenced studies that support the recommendations are summarized in Online Data Supplement 24. COR LOE Recommendations 1 B-NR 1. In patients with acute chest pain and myocardial injury who have nonobstructive coronary arteries on anatomic testing, CMR with gadolinium contrast is effective to distinguish myopericarditis from other causes, including myocardial infarction and nonobstructive coronary arteries (MINOCA).1-6 1 B-NR 2. In patients with acute chest pain with suspected acute myopericarditis, CMR is useful if there is diagnostic uncertainty, or to determine the presence and extent of myocardial and pericardial inflammation and fibrosis.7-12 1 C-EO 3. In patients with acute chest pain and suspected myopericarditis, TTE is effective to determine the presence of ventricular wall motion abnormalities, pericardial effusion, valvular abnormalities, or restrictive physiology. 2b C-LD 4. In patients with acute chest pain with suspected acute pericarditis, noncontrast or contrast cardiac CT scanning may be reasonable to determine the presence and degree of pericardial thickening.7,8,13 Downloaded from http://ahajournals.org by on October 7, 2026