From the Guidelines
Acute aortic dissection typically presents with sudden, severe chest or back pain often described as sharp or stabbing in nature, and may be accompanied by other signs and symptoms such as differences in blood pressure between arms, a new murmur of aortic regurgitation, and neurological symptoms like syncope or stroke. The diagnosis of acute aortic dissection can be challenging due to overlapping symptoms with other common emergency department complaints 1. According to the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease, patients with acute aortic dissection may present with various additional signs and symptoms, including pulse deficits, neurological symptoms, and signs of end-organ ischemia 1. It is essential to record a careful history of the presenting symptoms and obtain a detailed family history of thoracic aortic aneurysms, genetic aortopathies, aortic dissection, or unexplained sudden death 1. Blood pressure should be measured in both arms and both lower extremities to exclude a blood pressure differential resulting from an acute aortic dissection, and one should auscultate for the murmurs of aortic stenosis and aortic regurgitation 1. The 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease also emphasize the importance of evaluating patients with complaints that may represent acute thoracic aortic dissection to establish a pretest risk of disease, including specific questions about medical history, family history, and pain features, as well as a focused examination to identify findings associated with aortic dissection 1. Key features that increase the pretest risk of thoracic aortic dissection include high-risk conditions and historical features, such as Marfan syndrome, Loeys-Dietz syndrome, and family history of aortic dissection or thoracic aortic aneurysm, as well as high-risk chest, back, or abdominal pain features, such as pain that is abrupt or instantaneous in onset, severe in intensity, and has a ripping, tearing, stabbing, or sharp quality 1. Given the high mortality rate associated with acute aortic dissection, immediate medical attention is essential, and diagnosis typically requires imaging studies such as CT angiography, transesophageal echocardiography, or MRI 1. Some key signs and symptoms to look out for include:
- Sudden, severe chest or back pain
- Differences in blood pressure between arms
- New murmur of aortic regurgitation
- Pulse deficits
- Neurological symptoms like syncope or stroke
- Signs of end-organ ischemia such as acute kidney injury or mesenteric ischemia
- Shortness of breath, sweating, anxiety, and signs of shock including hypotension and tachycardia.
From the Research
Signs and Symptoms of Acute Aortic Dissection
- Severe chest pain, often described as tearing or ripping, which can radiate to the back 2, 3, 4, 5
- Hypotension or syncope 3, 4
- Symptoms related to acute aortic insufficiency and/or pericardial tamponade 4
- Variable acute neurologic alterations 4
- Signs of peripheral or visceral malperfusion 4
- Abdominal pain, back pain, or acute congestive heart failure 6
- Anuria, pulse deficits, or syncope 6
Diagnostic Considerations
- Diagnostic imaging is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of acute aortic dissection 2
- CT fast acquisition of volumetric datasets has become instrumental in diagnosis, surveillance, and intervention planning 2
- Transthoracic echocardiogram and computed tomography are initial clinical diagnostic studies 4
- Blood tests play only a small role in diagnosis, but have the potential to make diagnosis and monitoring of patients simpler and more cost-effective 3
Clinical Presentations and Misdiagnosis
- Acute aortic dissection can present with a variety of clinical manifestations, making it difficult to diagnose correctly 4, 6
- Initial misdiagnosis can occur, with myocardial infarction or cerebral infarction being common misdiagnoses 6
- A high level of vigilance is necessary to detect and treat visceral ischemia 4
- Maintaining a high level of suspicion for acute aortic dissection is key in its management 6