What does aortic dissection pain feel like?

Characteristics of Aortic Dissection Pain

Aortic dissection typically presents with sudden-onset, severe pain that is maximal at onset and often described as sharp, tearing, ripping, or stabbing in quality, with the abruptness of onset being the most specific characteristic. 1

Classic Pain Presentation

• Onset and Quality:

  • Pain begins abruptly and reaches maximum intensity immediately (unlike myocardial infarction pain which builds gradually) 2, 1
  • Described as sharp, tearing, ripping, or stabbing 2, 1
  • Only about 60% of patients with Type A dissection describe their pain as sharp 3

• Location:

  • Proximal (Type A) dissections: Typically retrosternal chest pain 2, 1
  • Distal (Type B) dissections: Typically interscapular or back pain 2, 1
  • Pain may migrate as the dissection progresses 1

Atypical Presentations

Aortic dissection can present atypically in up to 40% of cases 1, which contributes to missed or delayed diagnoses in approximately 35% of cases 3:

• Painless dissection: Occurs in approximately 6.4% of patients, more common in older patients, those on steroids, or with Marfan syndrome 1
• Abdominal pain: Present in about 25% of patients with aortic dissection 1
• Syncope: Occurs in up to 20% of patients, sometimes without pain 2, 1
• Other presentations:
  • Congestive heart failure symptoms due to aortic regurgitation 2, 1
  • Stroke-like symptoms 1
  • Pulse deficits (present in up to 20% of acute cases) 1
  • Paraplegia due to spinal cord ischemia 2, 1
  • Renal symptoms (oliguria/anuria) 2

Distinguishing Features from Other Conditions

• Versus myocardial infarction:

  • Aortic dissection pain is maximal at onset and sharp/tearing
  • MI pain typically starts slowly, increases gradually, and is more dull/oppressive 2

• Common misdiagnoses:

  • Acute coronary syndrome
  • Pericarditis
  • Pulmonary embolism
  • Cholecystitis 2, 3

Risk Factors to Consider

Patients with these risk factors should raise suspicion for aortic dissection when presenting with compatible pain:

• Hypertension (present in 65-75% of cases) 1
• Male gender
• Advanced age
• Pre-existing aortic diseases
• Genetic connective tissue disorders (Marfan, Loeys-Dietz, Ehlers-Danlos syndromes) 1

Clinical Pitfalls

• Patients with abdominal pain as the primary symptom are less likely to be suspected of having aortic dissection (only 8% compared to 86% for those with chest and back pain) 1
• ECG changes may mimic acute coronary syndrome, leading to misdiagnosis 4
• Painless presentations are easily missed and may present with syncope, stroke, or heart failure 1
• Patients with atypical symptoms like isolated shortness of breath may have complications such as diffuse alveolar hemorrhage 5

Remember that the classic triad of sudden-onset severe pain, pulse deficits, and blood pressure differentials is not always present. The abrupt onset of maximal pain is the most consistent and reliable symptom when present.