What are the signs and symptoms of aortic dissection?

Signs and Symptoms of Aortic Dissection

Aortic dissection most commonly presents with abrupt onset of severe, sharp chest or back pain that is maximal at the time of onset, occurring in up to 90% of patients, though clinicians must remain vigilant for atypical presentations including painless dissection in up to 6.4% of cases. 1, 2

Classic Pain Presentation

Pain Characteristics

• Abrupt onset with maximum intensity at the start (84% of cases), distinguishing it from myocardial infarction which typically builds gradually 1, 3
• Severe intensity in 90% of cases 3
• Sharp or stabbing quality (51-64% of cases) rather than the classic "tearing" or "ripping" description 2
• Migrating quality in 12-55% of cases as the dissection extends 2

Pain Location by Dissection Type

• Type A dissections (ascending aorta):

  • Chest pain in 80% of cases, more commonly anterior (71%) than posterior (32%) 2
  • Retrosternal location is typical 1, 3
  • Back pain occurs in 47% of Type A cases when dissection extends into descending aorta 2

• Type B dissections (descending aorta only):

  • Back pain in 64% of cases, typically interscapular 2
  • Abdominal pain in 43% of Type B cases 2

Critical pitfall: When only chest pain is present without back pain, dissection is suspected in only 45% of cases; when primarily abdominal pain is present, dissection is suspected in only 8% of cases, leading to missed diagnoses 2

Painless Presentations (6.4% of Cases)

Up to 20% of patients present with syncope without typical pain or neurological findings, particularly in older patients, those on steroids, and patients with Marfan syndrome 1, 2, 3

These patients more commonly present with: 2, 3

• Syncope (from severe pain, cerebral vessel obstruction, cardiac tamponade, or aortic baroreceptor activation)
• Stroke or cerebrovascular manifestations
• Congestive heart failure (usually from severe aortic regurgitation)

Cardiovascular Signs

Pulse Abnormalities

• Pulse deficits occur in less than 20% of current patients (historically 50% in older series) 1
• These pulse phenomena may be transient due to the intimal flap's changing position 1
• Limb ischemia from obliteration of peripheral vessels by the dissection 1, 3

Cardiac Manifestations

• Diastolic murmur indicative of aortic regurgitation in approximately 50% of patients 1
• Congestive heart failure as the predominant symptom, usually from severe aortic regurgitation 1, 3
• Cardiac tamponade resulting in hypotension and syncope 1, 3
• Hypotension particularly with proximal dissection and tamponade 1

Blood Pressure Findings

• Hypertension is typically associated with distal (Type B) aortic dissection 1, 3
• Blood pressure differential between arms or between upper and lower extremities 1

Neurological Manifestations

• Neurological deficits (loss of consciousness, ischemic paresis) occur in up to 40% of patients with proximal dissection 1
• Stroke or cerebrovascular accident without pain 1
• Paraplegia from sudden separation of intercostal arteries from the aortic lumen 1
• Horner's syndrome from compression of the superior cervical sympathetic ganglion 1
• Vocal cord paralysis from compression of the left recurrent laryngeal nerve 1

Visceral and Renal Manifestations

• Oliguria or anuria from renal artery involvement 1, 3
• Persistent abdominal pain with elevation of acute phase proteins and lactate dehydrogenase indicating celiac artery involvement (8% of cases) 1
• Mesenteric artery involvement in 8-13% of cases 1

Rare Presentations

• Hemoptysis or hematemesis from hemorrhage into the tracheobronchial tree or esophageal perforation 1
• Superior vena cava syndrome 1
• Upper airway obstruction from compression 1
• Signs mimicking pulmonary embolism from pulmonary artery compression 1
• Leriche's syndrome (painless pulse loss in both legs) from complete iliac bifurcation obstruction 1
• High fever from release of pyrogenic substances from the aortic wall, which can persist and be misinterpreted as inflammatory disease 1

Typical Patient Profile

The typical patient is a male in his 60s with a history of hypertension presenting with abrupt onset chest pain 1, 3

Major clinical pitfall: Aortic dissection can mimic acute coronary syndrome, and administering thrombolytic therapy to a patient with aortic dissection misdiagnosed as myocardial infarction can be catastrophic 3. Treating clinicians fail to initially consider the diagnosis in up to 35% of cases 4.