What are the typical symptoms and signs of aortic dissection?

Symptoms of Aortic Dissection

Primary Presentation

Aortic dissection most commonly presents with abrupt onset of severe, sharp 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 20% present with syncope and 6.4% have no pain at all. 1, 2

The pain characteristics that distinguish aortic dissection from other acute conditions include:

• Abrupt onset with maximum intensity at the beginning occurs in 84% of cases, fundamentally different from myocardial infarction which builds gradually 1, 3, 2
• Severe intensity is reported in 90% of cases 1, 2
• Sharp or stabbing quality in 51-64% of cases—notably, the classic "tearing" or "ripping" description is actually less common than sharp pain 1, 2
• Migrating pain occurs in 12-55% of cases as the dissection extends along the aorta 1

Pain Location 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%) 1
• Back pain develops in 47% when dissection extends into the descending aorta 1
• Retrosternal pain is the classic location for proximal dissections 4, 3

Type B Dissection (Descending Aorta)

• Back pain occurs in 64% of cases, typically interscapular 1
• Abdominal pain is reported in 43% of Type B cases 1
• Interscapular and back pain characterize distal dissections 4, 3

Atypical and Painless Presentations

Critical pitfall: 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. 4, 1, 3, 2

Painless presentations include:

• Syncope alone without chest or back pain 4, 1, 3, 2
• Congestive heart failure as the predominant symptom, usually from severe aortic regurgitation 4, 1, 3
• Isolated cerebrovascular accident (stroke) without pain 4, 1, 2
• Peripheral pulse loss without pain 1, 2
• Incidental abnormal chest radiograph without symptoms 1, 2
• Approximately 6.4% present completely painless, especially older individuals 1, 2

Cardiovascular Signs and Complications

Physical examination findings that suggest aortic dissection:

• Pulse deficits occur in less than 20% of current patients (historically 50% in older series) 1
• Blood pressure differential between arms or between upper and lower extremities (>20 mmHg systolic difference strongly suggests dissection) 2
• Diastolic murmur indicating aortic regurgitation in approximately 50% of patients 1
• Hypertension is typically associated with distal (Type B) aortic dissection 4, 1, 3
• Cardiac tamponade resulting in hypotension and syncope 4, 1, 3

Neurological Manifestations

Neurological deficits occur in up to 40% of patients with proximal dissection and include: 1

• Loss of consciousness 1
• Ischemic paresis 1
• Stroke or cerebrovascular accident without pain 4, 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 Complications

Organ malperfusion symptoms include:

• 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 ischemia from mesenteric artery involvement in 8-13% of cases 1

Rare Presentations

Less common manifestations that can mislead diagnosis:

• 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. 4, 1, 3, 2

Critical Clinical Caveat

Pain resolution does not exclude acute aortic dissection—re-emergence or change in pain location indicates possible propagation of the dissection and warrants immediate re-evaluation, irrespective of any prior pain-free interval. 2 Treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases, often initially suspecting acute coronary syndrome, pericarditis, pulmonary embolism, or cholecystitis instead. 5