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cardio.aortic-dissection.core.v1

Aortic dissection (Stanford A / B + IMH / PAU)

cardiologyacuteadultacuteinpatient
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4-step regimen (anti-impulse BB → vasodilator → type-specific repair → lifelong oral BB+ARB) authored without RxCUIs (atoms file pending RxCUI lookup); ED + ICU setting playbooks; six severity triggers including Type A surgery, Type B complicated TEVAR, tamponade overlap, malperfusion, pregnancy, cocaine. No `_design-brief.md` in src/lib/tier3/problem-package/packages/aortic-dissection — author one before promoting to INTEGRATED. Registry lacks an aortic-dissection-specific calculator (no DISSECT/IRAD-style score) — flagged for future addition. Manifest cites Isselbacher 2022 + ESC 2024 + STS/AATS 2024 + IRAD without inline PMIDs; backfill the citations after a research pass.

Entry points (4)

  • symptom
    Tearing / migrating chest or back pain (ACC/AHA 2022 Isselbacher — classic presentation; IRAD Hagan JAMA 2000)
    tearing_chest_pain
  • vital_abnormality
    Inter-arm SBP gradient ≥20 mmHg (ACC/AHA 2022 Isselbacher; ESC 2024)
    inter_arm_bp_gradient
  • symptom
    Syncope with chest/back pain (ACC/AHA 2022 — high-risk feature)
    syncope_with_chest_pain
  • imaging
    CTA showing aortic dissection / IMH / PAU (ACC/AHA 2022 Class I imaging)
    cta_dissection

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Risk of dissection rises with age + HTN (IRAD Hagan JAMA 2000)
  • sbprequired
    vital • used at RED_FLAGS
    Bilateral arm SBP for inter-arm gradient + impulse-therapy target (ACC/AHA 2022 Isselbacher)
  • hrrequired
    vital • used at TREATMENT
    Beta-blocker FIRST — target HR <60 before vasodilator (ACC/AHA 2022 Class I; ESC 2024)
  • pain_qualityrequired
    symptom • used at ENTRY
    Tearing/migrating quality + abrupt onset suggest dissection (IRAD Hagan JAMA 2000; ACC/AHA 2022)
  • cta_chest_abd_pelvisrequired
    imaging • used at INITIAL_WORKUP
    Definitive dx — Stanford A vs B, malperfusion, IMH/PAU (ACC/AHA 2022 Class I; ESC 2024)
  • connective_tissue_disorder
    history • used at CONTEXT
    Marfan / Loeys-Dietz / vascular EDS lower threshold (ACC/AHA 2022 Isselbacher)
  • pregnancy
    history • used at CONTEXT
    Third-trimester / peripartum dissection management differs (ACC/AHA 2022; ACOG)
  • cocaine_use
    history • used at CONTEXT
    Cocaine-precipitated dissection; AVOID beta-blocker monotherapy acute (ACC/AHA 2022)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal malperfusion; contrast planning (ACC/AHA 2022)
  • d_dimer
    lab • used at INITIAL_WORKUP
    Elevated d-dimer supports dissection vs alternate dx (ESC 2024; Suzuki Circulation 2009)

12-phase flow (10)

  1. 1FRAME
    Time-critical: type A surgical emergency — 1-2% mortality/h untreated (IRAD Hagan JAMA 2000; ACC/AHA 2022 Isselbacher)
    inputs: sbp
    advance: dissection suspected
  2. 2ENTRY
    Capture pain quality + abrupt onset + risk factors (ACC/AHA 2022; IRAD)
    inputs: age
    advance: high-suspicion presentation
  3. 3CONTEXT
    Bilateral arm BP, pulses, neurologic exam, family history (ACC/AHA 2022 Isselbacher; ESC 2024)
    inputs: sbp, connective_tissue_disorder, cocaine_use
    advance: context complete
  4. 4RED_FLAGS
    Hypotension/shock, neurologic deficit, mesenteric/limb ischemia, AR, tamponade (ACC/AHA 2022 — malperfusion syndromes)
    inputs: sbp
    actions: cardiac_tamponade
    advance: malperfusion / tamponade screen complete
  5. 5INITIAL_WORKUP
    CTA chest+abdomen+pelvis — definitive (ACC/AHA 2022 Class I); ECG to exclude STEMI; BMP + troponin + d-dimer (ESC 2024)
    inputs: cta_chest_abd_pelvis, creatinine, d_dimer
    actions: panel.cardiac, panel.renal
    advance: CTA confirms or rules out
  6. 6DIFFERENTIAL
    Stanford A vs B; complicated vs uncomplicated B; IMH / PAU; classify malperfusion territories (ACC/AHA 2022 Isselbacher)
    inputs: cta_chest_abd_pelvis
    advance: classification documented
  7. 7RISK_STRATIFICATION
    IRAD risk stratification; pregnancy + connective-tissue modifiers (ACC/AHA 2022)
    advance: risk class assigned
  8. 8TREATMENT
    Anti-impulse: IV beta-blocker FIRST to HR <60, then vasodilator to SBP 100-120 (ACC/AHA 2022 Class I; ESC 2024); pain control; STAT cardiothoracic for type A; TEVAR for complicated type B (INSTEAD Nienaber NEJM 2013)
    inputs: sbp, hr
    advance: BP/HR at target and surgical/endovascular plan in motion
  9. 9DISPOSITION
    Type A → OR (ACC/AHA 2022 Class I); type B complicated → TEVAR (INSTEAD Nienaber NEJM 2013; ESC 2024); type B uncomplicated → ICU medical
    advance: disposition assigned
  10. 10MONITORING
    Arterial line, q5min BP, neurologic + perfusion checks q1h (ACC/AHA 2022; ESC 2024)
    inputs: sbp
    advance: monitoring plan in place