What are the symptoms and treatment of aortic dissection?

Symptoms and Treatment of Aortic Dissection

Clinical Presentation

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 you must remain vigilant for painless presentations in up to 6.4% of cases. 1, 2

Pain Characteristics

The pain pattern differs markedly from myocardial infarction and provides critical diagnostic clues:

• Onset and intensity: Abrupt onset with maximum intensity at the start occurs in 84% of cases, distinguishing it from MI which builds gradually 1, 3
• Severity: Severe intensity reported in 90% of cases 1
• Quality: Sharp or stabbing in 51-64% of cases—the classic "tearing" or "ripping" description is actually less common than traditionally taught 1, 2
• Migration: Pain migrates in 12-55% of cases as the dissection extends 1, 2

Pain Location by Dissection Type

Type A dissections (ascending aorta):

• Chest pain in 80% of cases, more commonly anterior (71%) than posterior (32%) 1, 2
• Back pain in 47% when dissection extends into descending aorta 1, 2
• Abdominal pain in 21% 2

Type B dissections (descending aorta only):

• Back pain in 64%, typically interscapular 1, 2
• Abdominal pain in 43% 1, 2

Painless Presentations—A Critical Pitfall

Up to 6.4% of patients present without pain, particularly:

• Older patients 1, 2
• Patients on steroids 1, 2
• Patients with Marfan syndrome 1, 2

These patients more commonly present with syncope (up to 20% of all cases), stroke, or congestive heart failure 1, 3, 2

Cardiovascular Manifestations

• Pulse deficits: Occur in less than 20% of current patients (historically 50% in older series) 1
• Aortic regurgitation: Diastolic murmur in approximately 50% of patients 1
• Congestive heart failure: Predominant symptom from severe aortic regurgitation 1, 3
• Cardiac tamponade: Causes hypotension and syncope 1, 3
• Hypertension: Typically associated with Type B dissection 4, 3
• Blood pressure differential: Between arms or between upper and lower extremities 1

Neurological Manifestations

• Neurological deficits: Loss of consciousness or ischemic paresis in up to 40% of patients with proximal dissection 1
• Stroke: May occur without pain 1
• Paraplegia: From sudden separation of intercostal arteries 1
• Horner's syndrome: From compression of superior cervical sympathetic ganglion 1
• Vocal cord paralysis: From compression of left recurrent laryngeal nerve 1

Visceral and Renal Complications

• Oliguria or anuria: From renal artery involvement 1, 3
• Mesenteric ischemia: Occurs in 8-13% of cases with persistent abdominal pain and elevated lactate dehydrogenase 1

Typical Patient Profile

The typical patient is a male in his 60s with a history of hypertension presenting with abrupt onset chest pain 4, 1, 3

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Treatment Approach

Immediate Medical Management

Reduce systolic blood pressure to 100-120 mmHg using IV beta-blockers as first-line therapy, targeting a heart rate of 60 beats per minute or less. 3

• Beta-blockers first: IV beta-blockers are the initial therapy 3
• Add vasodilators if needed: For severe hypertension despite beta-blockade, add sodium nitroprusside 3
• Pain control: Provide morphine sulfate for pain relief 3
• ICU transfer: Transfer to intensive care unit for appropriate monitoring 3

Definitive Management by Type

Type A dissection (involving ascending aorta):

• Urgent surgical consultation and evaluation for emergent surgical repair 3
• Surgical options include implantation of a composite graft in the ascending aorta 3

Type B dissection (involving descending aorta):

• Initially manage medically unless life-threatening complications develop 3
• For complicated Type B dissection, emergency intervention with TEVAR (Thoracic Endovascular Aortic Repair) is recommended 3

Diagnostic Imaging

Every patient with suspected aortic dissection should undergo urgent definitive imaging with TEE, CT, or MRI based on patient variables and institutional capabilities. 3

Critical Pitfalls to Avoid

Thrombolytic therapy can be catastrophic if administered to a patient with aortic dissection misdiagnosed as myocardial infarction. 3 The overlapping presentation with acute coronary syndrome demands imaging before thrombolysis in any patient with atypical features or risk factors for dissection.

Maintain high clinical suspicion in patients with:

• Difficult-to-control hypertension 5
• Genetic connective tissue disorders (Marfan, Loeys-Dietz, Ehlers-Danlos) 3, 6
• Bicuspid aortic valve 3, 6
• Family history of aortic disease 6, 5
• Ischemic symptoms involving multiple organs without obvious cause 5