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 as up to 6.4% present without pain at all. 1

Pain Characteristics

The pain of aortic dissection has distinctive features that differentiate it from other acute conditions:

• Abrupt onset with maximum intensity at the start occurs in 84% of cases, which distinguishes it from myocardial infarction pain that typically builds gradually 2, 1
• Severe intensity is reported in 90% of cases 1
• Sharp or stabbing quality occurs in 51-64% of cases, rather than the classic "tearing" or "ripping" description that is often taught 3, 1
• Migrating quality is reported in 12-55% of cases as the dissection extends along the aorta 1, 4

Pain Location by Dissection Type

The location of pain varies predictably based on which portion of the aorta is involved:

Type A Dissections (Ascending Aorta)

• Chest pain occurs in 80% of cases, more commonly anterior (71%) than posterior (32%) 1, 4
• Back pain occurs in 47% of Type A cases when dissection extends into the descending aorta 1, 4
• Abdominal pain occurs in 21% of Type A cases 4

Type B Dissections (Descending Aorta Only)

• Back pain occurs in 64% of cases, typically interscapular 2, 1, 4
• Abdominal pain occurs in 43% of Type B cases 1, 4

Cardiovascular Signs and Symptoms

Beyond pain, several cardiovascular manifestations should raise suspicion:

• Pulse deficits occur in less than 20% of current patients (though historically reported in 50% in older series) 1
• Diastolic murmur indicative of aortic regurgitation is present in approximately 50% of patients 1
• Congestive heart failure may become the predominant symptom, usually related to severe aortic regurgitation 2, 1
• Cardiac tamponade can cause hypotension and syncope 2, 1
• Blood pressure differential between arms or between upper and lower extremities is a significant finding 1
• Hypertension is more commonly associated with distal (Type B) aortic dissection 2, 1

Neurological Manifestations

Neurological complications occur frequently and can dominate the clinical picture:

• Syncope occurs in up to 20% of patients without typical pain or neurological findings, particularly in older patients, those on steroids, and patients with Marfan syndrome 2, 1
• Neurological deficits (loss of consciousness, ischemic paresis) occur in up to 40% of patients with proximal dissection 1
• Stroke or cerebrovascular accident without pain is a potential complication 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

Involvement of branch vessels can produce organ-specific symptoms:

• Oliguria or anuria from renal artery involvement 2, 1
• Persistent abdominal pain with elevation of acute phase proteins and lactate dehydrogenase indicating celiac artery involvement (8% of cases) 1
• Mesenteric artery involvement occurs in 8-13% of cases 1
• Limb ischemia may result from obliteration of peripheral vessels 2

Rare and Atypical Presentations

Clinicians must maintain vigilance for uncommon presentations:

• Painless dissection occurs in up to 6.4% of cases, with patients more commonly presenting with syncope, stroke, or congestive heart failure 1, 4
• 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
• Sinus tachycardia as the only presenting sign 5

Typical Patient Profile

The typical patient is a male in his 60s with a history of hypertension presenting with abrupt onset chest pain. 2, 1

Critical Clinical Pitfalls

• Treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases 6
• Only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp 6
• Thrombolytic therapy can be catastrophic if administered to a patient with aortic dissection misdiagnosed as myocardial infarction 2
• Patients are often initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or cholecystitis 6

Essential Physical Examination Findings

When aortic dissection is suspected, specific examination findings should be sought:

• Blood pressure should be measured in both arms and both lower extremities to exclude a BP differential resulting from dissection 3
• Auscultate for murmurs of aortic stenosis (perhaps indicating an underlying bicuspid aortic valve) and aortic regurgitation, which commonly accompanies type A aortic dissection 3