What are the signs and symptoms of aortic dissection in older adults with a history of hypertension, atherosclerosis, or other cardiovascular diseases, and certain genetic conditions such as Marfan syndrome?

Aortic Dissection Signs and Symptoms

Aortic dissection presents most characteristically with abrupt-onset, severe chest or back pain that reaches maximum intensity immediately at onset, often described as tearing, ripping, or stabbing in quality—a presentation fundamentally different from myocardial infarction where pain typically builds gradually. 1, 2

Pain Characteristics

Location by Dissection Type

• Type A dissections (involving ascending aorta) present with anterior chest pain in 80% of cases, though back pain occurs in 47% when dissection extends into the descending aorta 3
• Type B dissections (descending aorta only) present with interscapular back pain in 64% of cases 3
• Abdominal pain occurs in 21% of Type A and 43% of Type B dissections 3

Pain Quality and Onset

• Abrupt onset occurs in 84% of cases, with pain reaching maximum intensity immediately rather than building gradually 2, 3
• Severe intensity is present in 90% of cases 2
• Sharp or stabbing quality in 51-64% of cases—the classic "tearing" or "ripping" description is actually less common than traditionally taught 3
• Migrating pain occurs in 12-55% of cases as the dissection extends 3

Critical Exception

• 6.4% of patients present without pain, particularly older patients, those on steroids, and patients with Marfan syndrome—these patients more commonly present with syncope, stroke, or heart failure 3

High-Risk Examination Features

Providers must systematically assess for these physical findings that strongly suggest dissection: 4

• Pulse deficit (absent or diminished peripheral pulses) 4
• Systolic blood pressure differential >20 mmHg between limbs 4
• New murmur of aortic regurgitation 4
• Focal neurologic deficits (occur in 17-40% of patients and may mask the underlying condition) 4, 5

Associated Symptoms and Complications

• Syncope occurs in up to 20% of cases, often related to cardiac tamponade or neurologic injury 1, 3
• Hypotension or shock from cardiac tamponade or rupture 1
• Cardiac failure from severe acute aortic regurgitation 1
• Limb ischemia from peripheral vessel obliteration 1
• Oliguria or anuria with renal artery involvement 1
• Paraplegia from spinal artery involvement 3

High-Risk Patient Populations

These conditions dramatically increase dissection risk and should trigger heightened suspicion: 4

Genetic Conditions

• Marfan syndrome (present in 50% of dissection patients under age 40) 4
• Loeys-Dietz syndrome 4
• Vascular Ehlers-Danlos syndrome 4
• Turner syndrome 4
• Genetic mutations in FBN1, TGFBR1, TGFBR2, ACTA2, or MYH11 4

Cardiovascular Risk Factors

• Hypertension (present in 65-75% of cases, often poorly controlled) 4, 2
• Known thoracic aortic aneurysm 4
• Bicuspid aortic valve 4
• Family history of aortic dissection or thoracic aneurysm (13-19% of patients have affected first-degree relatives) 4
• Recent aortic manipulation (surgical or catheter-based) 4

Demographic Profile

• Typical patient: male in his 60s with hypertension 1, 2
• Elderly patients (≥70 years) present with atypical symptoms more frequently—typical chest/back pain and classic signs like aortic regurgitation murmur or pulse deficits are less common in this age group 6

Age-Related Differences

Older patients (≥70 years) present differently than younger patients: 6

• Less likely to have typical abrupt chest or back pain
• Less likely to have aortic regurgitation murmur or pulse deficits
• More likely to have hypotension (46% vs 32% in younger patients)
• Less likely to have focal neurologic deficits (18% vs 26% in younger patients)
• Higher in-hospital mortality (43% vs 28%)

Critical Diagnostic Pitfall

Neurological symptoms occur in 17-40% of patients and can completely mask the underlying aortic pathology, especially in the 5-15% of patients who present without pain. 5 These patients are at extreme risk of misdiagnosis as stroke, and administering thrombolysis can be catastrophic. 1 Always assess for chest/back pain, pulse deficits, and blood pressure differentials in any patient presenting with acute neurologic complaints. 4