What are the signs and symptoms of aortic dissection?

Signs and Symptoms of Aortic Dissection

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 location varying based on the type of dissection—chest pain for Type A (proximal) and back pain for Type B (distal) dissections. 1

Cardinal Symptoms

• Pain characteristics:

  • Sudden onset with maximum intensity at the beginning 2, 1
  • Sharp, tearing, ripping, or stabbing quality (51-64% of cases) 2
  • May have a migrating quality (12-55% of cases) as dissection extends 2
  • May ease or abate, potentially leading to false reassurance 2

• Pain location by dissection type:

  • Type A (proximal) dissections:

    • Chest pain (80%), more commonly anterior (71%) than posterior (32%) 2
    • Back pain (47%) 2
    • Abdominal pain (21%) 2
    • Typically retrosternal in location 2, 1

  • Type B (distal) dissections:

    • Back pain (64%) 2
    • Chest pain (63%) 2
    • Abdominal pain (43%) 2
    • Typically interscapular in location 2, 1

Atypical Presentations

• Painless dissection (6.4% of cases) 2, 1

  • More common in older patients 1
  • More likely to present with syncope, stroke, or heart failure 2, 1
  • More common in patients on steroids or with Marfan syndrome 2

• Other presenting symptoms:

  • Syncope (up to 20% of cases) 2, 1
  • Congestive heart failure due to aortic regurgitation 2, 1
  • Stroke or neurological deficits 1
  • Paraplegia from spinal cord ischemia 1
  • Renal symptoms (oliguria/anuria) 1
  • Painful or numb lower extremities 2, 1
  • Shortness of breath (rarely as the primary symptom) 3

Physical Examination Findings

• Cardiovascular signs:

  • Pulse deficits (up to 20% of patients, historically up to 50% in proximal dissections) 1
  • Blood pressure differential between arms 1
  • Diastolic murmur of aortic regurgitation (approximately 50% of patients) 1
  • Signs of cardiac tamponade (muffled heart sounds, jugular venous distention, hypotension) 1
  • Hypertension (typically associated with distal dissections) 2

• End-organ ischemia signs:

  • Focal neurologic deficits 1
  • Limb ischemia 1
  • Mesenteric ischemia 1
  • Vocal cord paralysis 1

Risk Factors to Consider

• Conditions increasing suspicion:
  • Hypertension (most common risk factor) 2, 1
  • Male gender, advanced age 1
  • Pre-existing aortic diseases 1
  • Genetic connective tissue disorders (e.g., Marfan syndrome) 2, 1
  • Bicuspid aortic valve 2
  • Pregnancy 2
  • Cocaine or stimulant use 2

Clinical Pitfalls and Diagnostic Challenges

1. Pain location affects diagnostic suspicion:

   • When patients present with both chest and back pain, dissection is suspected in 86% of cases
   • With chest pain alone, suspicion drops to 45%
   • With primarily abdominal pain, suspicion is only 8% 2, 1

2. Common misdiagnoses:

   • Acute coronary syndrome (distinguishable by sudden onset and sharp quality of dissection pain vs. gradually increasing, dull pain of MI) 2, 1
   • Pericarditis 2, 4
   • Pulmonary embolism 2, 4
   • Cholecystitis 2, 4

3. Rare presentations that may be missed:

   • Diffuse alveolar hemorrhage with respiratory symptoms 3
   • Isolated sinus tachycardia 5
   • Completely asymptomatic (incidental finding) 6

Remember that timely recognition of aortic dissection is critical, as untreated Type A dissections have a mortality rate of approximately 75% within 2 weeks, but with appropriate management, 5-year survival increases to 75% 7.