What are the symptoms of aortic dissection?

Symptoms of Aortic Dissection

Aortic dissection most commonly presents with abrupt onset of severe chest or back pain that reaches maximum intensity immediately at onset, occurring in up to 90% of patients, though clinicians must remain vigilant as up to 6.4% present without any pain at all. 1, 2

Cardinal 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, fundamentally different from myocardial infarction which typically builds gradually 2
• Severe intensity is reported in 90% of cases 2
• Sharp or stabbing quality occurs in 51-64% of cases, rather than the classically described "tearing" or "ripping" sensation 2
• Migrating quality is present in 12-55% of cases as the dissection extends along the aorta 2

Location of Pain by Dissection Type

The anatomic location of pain provides critical diagnostic clues:

Type A Dissection (Ascending Aorta)

• Chest pain occurs in 80% of cases, predominantly anterior (71%) rather than posterior (32%) 2
• Back pain develops in 47% when dissection extends into the descending aorta 2
• Retrosternal pain is characteristic of proximal dissections 1

Type B Dissection (Descending Aorta)

• Back pain occurs in 64% of cases, typically interscapular 1, 2
• Abdominal pain is reported in 43% of cases 2

Cardiovascular Manifestations

Cardiac complications produce distinct symptom patterns:

• Syncope occurs in approximately 13% of cases with multiple etiologies including cardiac tamponade, severe aortic regurgitation, impaired cerebral blood flow, vasovagal response to pain, or volume loss from false lumen rupture 3
• Congestive heart failure may become the predominant symptom, usually from severe aortic regurgitation 3, 1
• Cardiac tamponade presents with hypotension and syncope, occurring in 8-10% of Type A dissections and representing an ominous predictor of mortality 3
• Pulse deficits occur in less than 20% of current patients (historically 50% in older series) and may be transient due to changing intimal flap position 3, 2

Neurological Complications

Neurological symptoms occur frequently and may dominate the clinical picture:

• Neurological deficits (loss of consciousness, ischemic paresis) occur in up to 40% of patients with proximal dissection 3, 2
• Stroke is reported in 17% of pooled data from over 1300 patients; notably, up to one-third of patients with neurological symptoms present without chest pain, significantly complicating diagnosis 3
• Paraplegia from spinal cord malperfusion occurs in 1-3% of patients and may be the primary manifestation 3
• Horner's syndrome results from compression of the superior cervical sympathetic ganglion 3, 2
• Vocal cord paralysis occurs from compression of the left recurrent laryngeal nerve 3, 2

Critically, up to 50% of dissection-related neurological symptoms may be transient, further obscuring diagnosis 3

Blood Pressure Abnormalities

Blood pressure patterns vary significantly by dissection type:

• Hypertension is present in approximately half of patients at presentation, with 71% of Type B patients having systolic blood pressure >150 mmHg versus only 36% of Type A patients 3
• Hypotension or shock occurs in nearly 20% of patients and results from cardiac tamponade, aortic hemorrhage, severe aortic insufficiency, myocardial ischemia, or true lumen compression 3
• Blood pressure differential between limbs may occur due to dissection-related occlusion of branch arteries, requiring measurement in both arms and potentially both legs 3

Visceral and Renal Manifestations

Organ malperfusion produces characteristic symptom patterns:

• Oliguria or anuria develops with renal artery involvement 3, 1, 2
• Persistent abdominal pain with elevation of acute phase proteins and lactate dehydrogenase indicates celiac artery involvement in approximately 8% of cases 3, 2
• Mesenteric artery involvement occurs in 8-13% of cases 3, 2

Pulmonary Complications

Respiratory symptoms may be prominent:

• Pleural effusion is the most common pulmonary complication, noted in 16% of cases at presentation; large effusions result from blood leaking into the pleural space while small effusions are typically inflammatory exudates 3
• Dyspnea may result from dissection-related pulmonary artery compression or development of an aortopulmonary fistula 3
• Hemoptysis occurs in 3% of patients from compression of lung parenchyma or direct aneurysmal rupture into the lung 3

Atypical and Rare Presentations

Clinicians must maintain vigilance for uncommon manifestations:

• Painless dissection occurs in up to 6.4% of cases, particularly in older patients, those on steroids, and patients with Marfan syndrome 1, 2
• Superior vena cava syndrome may develop 3, 2
• Upper airway obstruction from compression 3, 2
• Signs mimicking pulmonary embolism from pulmonary artery compression 3, 2
• Leriche's syndrome (painless pulse loss in both legs) from complete iliac bifurcation obstruction 3, 2
• High fever from release of pyrogenic substances from the aortic wall, which can persist and be misinterpreted as inflammatory disease 3, 2
• Hematemesis from esophageal perforation 3, 2

Typical Patient Profile

The typical patient is a male in his 60s with a history of hypertension presenting with abrupt onset chest pain. 1, 2 However, patients with genetic connective tissue disorders (Marfan, Loeys-Dietz, Ehlers-Danlos syndrome) and bicuspid aortic valves develop dissection at much younger ages 1, 4

Critical Diagnostic Pitfall

Treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35-38% of cases, often initially suspecting acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis 5, 6 This represents a catastrophic missed diagnosis, as thrombolytic therapy administered to a patient with aortic dissection misdiagnosed as myocardial infarction can be fatal 1