Symptoms of Aortic Dissection
Aortic dissection classically presents with abrupt onset of severe chest or back pain that reaches maximum intensity immediately at onset—this sudden, peak-intensity pain at the very beginning is the most specific characteristic that distinguishes it from myocardial infarction, which typically builds gradually. 1
Cardinal Symptom: Pain
Pain characteristics:
- Abrupt onset with maximum intensity from the start is present in up to 90% of patients and is the most distinguishing feature 1
- Described as sharp, tearing, ripping, or knife-like in quality 1
- Location varies by dissection type:
- Pain may migrate as the dissection extends along the aorta 1
Presentations Without Pain (Critical Pitfall)
Up to 20% of patients present with syncope alone, without typical pain or neurological findings—this painless presentation is associated with higher mortality because diagnosis is often delayed. 1
Other painless presentations include:
- Congestive heart failure without pain 1
- Stroke without pain 1
- Abnormal chest X-ray discovered incidentally 1
- Isolated pulse deficits 1
- Sinus tachycardia as the only finding 2
Cardiovascular Manifestations
Syncope:
- Occurs in approximately 15% of Type A dissections and <5% of Type B dissections 1
- Associated with increased in-hospital mortality 1
- Caused by cardiac tamponade, severe pain, cerebral vessel obstruction, or aortic baroreceptor activation 1
Cardiac complications:
- Congestive heart failure from severe aortic regurgitation 1
- Hypotension and shock from cardiac tamponade, aortic rupture, or extensive myocardial ischemia 1
- Cardiogenic shock presentations often lack the characteristic severe chest pain, delaying diagnosis 1
Pulse abnormalities:
- Pulse deficits occur in less than 20% of patients currently (historically reported at 50%) 1
- These pulse phenomena may be transient due to the intimal flap's changing position 1
- Limb ischemia results from vessel obliteration by the dissection or false lumen expansion 1
Neurological Manifestations
Neurological deficits occur in up to 40% of patients with proximal dissection: 1
- Loss of consciousness 1
- Stroke or cerebrovascular accidents 1
- Ischemic paresis 1
- Paraplegia from intercostal artery involvement 1
- Horner's syndrome from superior cervical sympathetic ganglion compression 1
- Vocal cord paralysis from left recurrent laryngeal nerve compression 1
Renal and Abdominal Manifestations
- Oliguria or anuria from renal artery involvement 1
- Persistent abdominal pain with elevated acute phase proteins and lactate dehydrogenase indicates celiac artery involvement (8% of cases) 1
- Mesenteric artery involvement occurs in 8-13% of cases 1
- Abdominal presentations are often non-specific and painless in 40% of cases, leading to delayed diagnosis 1
Associated Clinical Features
Hypertension:
- Present in 65-75% of patients, typically poorly controlled 1
- More commonly associated with distal/Type B dissection 1
Typical patient profile:
Rare Presentations
- Pleural effusions (15-20% of patients) from inflammatory process or mediastinal bleeding 1
- Hemoptysis or hematemesis from hemorrhage into tracheobronchial tree or esophageal perforation 1
- Superior vena cava syndrome 1
- Upper airway obstruction 1
- High fever from pyrogenic substance release (can be misinterpreted as inflammatory disease) 1
- Massive hemoptysis from acute aortic rupture into the lung 1
Critical Diagnostic Pitfall
The absence of classic tearing chest pain does NOT rule out aortic dissection—approximately 20% present atypically, and these patients have worse outcomes due to delayed diagnosis. 1 Clinicians fail to initially consider aortic dissection in up to 35% of cases, often misdiagnosing as acute coronary syndrome, pericarditis, pulmonary embolism, or cholecystitis 3. Administering thrombolytic therapy to a patient with aortic dissection misdiagnosed as myocardial infarction can be catastrophic. 4