What are the symptoms and treatment of an aortic dissection?

Symptoms and Treatment of Aortic Dissection

The hallmark symptom of aortic dissection is abrupt onset of severe, sharp chest and/or back pain that reaches maximum intensity immediately and is often described as tearing, ripping, or knife-like in nature. 1

Clinical Presentation

Primary Symptoms

• Pain characteristics:
  • Sudden onset with maximum intensity at onset
  • Sharp, tearing, ripping, or knife-like quality
  • Different from other causes of chest pain (unlike myocardial infarction pain which builds gradually)
  • Location varies based on dissection type:
    • Type A (proximal): Retrosternal chest pain
    • Type B (distal): Back or interscapular pain, sometimes abdominal pain

Associated Symptoms and Signs

• Cardiovascular manifestations:

  • Aortic regurgitation murmur (in 40-75% of Type A dissections) 1
  • Pulse deficits (in up to 20% of cases) 1
  • Hypotension or shock (from rupture, tamponade, or severe aortic regurgitation)
  • Syncope (in 15% of Type A and <5% of Type B dissections) 1

• Neurological manifestations:

  • Stroke-like symptoms
  • Loss of consciousness
  • Paraplegia (from spinal artery involvement)
  • Horner's syndrome (from compression of superior cervical sympathetic ganglion)

• Other organ system involvement:

  • Oliguria/anuria (renal artery involvement)
  • Mesenteric ischemia (abdominal pain, elevated lactate dehydrogenase)
  • Limb ischemia
  • Vocal cord paralysis (from recurrent laryngeal nerve compression)

Atypical Presentations

• Up to 20% of patients may present with syncope without typical pain 1
• Heart failure symptoms may predominate in cases with severe aortic regurgitation
• Some patients may be completely asymptomatic (rare) 2, 3

Risk Factors

• Hypertension (present in 65-75% of cases) 1
• Advanced age (mean age 63 years)
• Male gender (65% of cases)
• Pre-existing aortic disease or aneurysm
• Genetic connective tissue disorders (Marfan, Loeys-Dietz, Ehlers-Danlos syndromes)
• Bicuspid aortic valve
• History of cardiac surgery
• Smoking
• Blunt chest trauma
• Intravenous drug use (cocaine, amphetamines)

Diagnostic Approach

Initial Assessment

• Vital signs with focus on blood pressure differences between extremities
• Cardiac examination for murmurs of aortic regurgitation
• Peripheral pulse examination for deficits
• Neurological examination

Imaging (essential for diagnosis)

• CT angiography (first-line)
• Transesophageal echocardiography
• MRI (for stable patients)
• Aortography (less commonly used today)

Treatment Algorithm

Immediate Management

1. Stabilize hemodynamics:

   • IV access, continuous monitoring
   • Control blood pressure (target systolic 100-120 mmHg)
   • Beta-blockers first (e.g., esmolol, labetalol, metoprolol)
   • Add vasodilators if needed (after adequate beta-blockade)
   • Pain management with opioids

2. Determine dissection type:

   • Type A (involving ascending aorta): SURGICAL EMERGENCY
   • Type B (limited to descending aorta): Usually medical management initially

Definitive Management

Type A Dissection

• Immediate surgical repair to prevent rupture, tamponade, and severe aortic regurgitation
• Surgery involves:
  • Replacement of the ascending aorta
  • Aortic valve repair/replacement if needed
  • Reimplantation of coronary arteries if needed

Type B Dissection

• Medical management for uncomplicated cases:

  • Strict blood pressure control
  • Beta-blockers
  • Pain management
  • Close monitoring

• Endovascular or surgical intervention for complicated cases:

  • Malperfusion syndromes
  • Rapid expansion
  • Rupture or impending rupture
  • Refractory pain
  • Refractory hypertension

Long-term Management

• Lifelong blood pressure control
• Beta-blockers
• Regular imaging surveillance
• Lifestyle modifications
• Genetic counseling if appropriate

Common Pitfalls to Avoid

1. Misdiagnosis as acute coronary syndrome - The abrupt onset and tearing quality of pain should raise suspicion for aortic dissection

2. Delayed diagnosis in atypical presentations - Consider aortic dissection in patients with:

   • Syncope without clear cause
   • Neurological deficits with hypertension
   • Unexplained pulse deficits or blood pressure differences between limbs

3. Administration of thrombolytics - Can be catastrophic if given for presumed myocardial infarction when the patient actually has aortic dissection

4. Inadequate blood pressure control - Failure to control both blood pressure and heart rate (force of left ventricular contraction) can lead to extension of dissection

5. Focusing only on the aorta - Missing end-organ complications from branch vessel involvement can lead to preventable morbidity and mortality

Remember that time is critical in aortic dissection management, with mortality increasing by 1-2% per hour in untreated patients 4. Early recognition of symptoms and prompt appropriate imaging are essential to improve survival.