In a middle‑aged to older male with hypertension or a connective‑tissue disorder (e.g., Marfan syndrome, bicuspid aortic valve), what clinical signs should raise suspicion for an aortic dissection?

Clinical Signs of Aortic Dissection

In a middle-aged to older male with hypertension or connective tissue disorder, suspect aortic dissection when sudden-onset severe chest or back pain is accompanied by pulse deficits, blood pressure differentials between limbs, new aortic regurgitation murmur, or neurologic deficits. 1, 2

High-Risk Historical Features

Patient Demographics and Conditions

• Male gender in the 6th-7th decade with chronic hypertension represents the classic presentation 2, 3, 4
• Connective tissue disorders: Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, or Turner syndrome 1, 5
• Genetic mutations in FBN1, TGFBR1, TGFBR2, ACTA2, or MYH11 genes 1
• Bicuspid aortic valve or known aortic valve disease 1, 5
• Family history of aortic dissection or thoracic aortic aneurysm 1, 6
• Recent aortic manipulation (surgical or catheter-based procedures) 1
• Known thoracic aortic aneurysm 1

Pain Characteristics That Demand Attention

• Abrupt or instantaneous onset (present in ~84% of cases) rather than gradual buildup 1, 6, 3
• Severe intensity at maximum from the very beginning (present in ~90% of cases) 3, 4
• Ripping, tearing, stabbing, or sharp quality (though sharp/stabbing is more common than the classic "tearing" description at 51-64%) 1, 6, 3
• Location predicts dissection type: retrosternal/anterior chest pain suggests Type A (ascending aorta) dissection in 71% of cases, while interscapular/back pain suggests Type B (descending aorta) dissection in 64% of cases 2, 6

Critical Physical Examination Findings

Vascular Signs (Most Specific)

• Pulse deficit in any extremity (found in <20% of current cases, but highly specific when present) 1, 2
• Systolic blood pressure differential >20 mmHg between arms 1, 6, 3
• Transient pulse phenomena may occur due to changing position of the intimal flap 1

Cardiac Signs

• New diastolic murmur of aortic regurgitation (present in approximately 50% of patients with proximal dissection) 1, 3
• Signs of cardiac tamponade: hypotension, muffled heart sounds, jugular venous distension 1, 2
• Acute heart failure symptoms from severe aortic regurgitation 1, 2

Neurologic Manifestations

• Focal neurologic deficits including stroke, ischemic paresis, or loss of consciousness (occur in up to 40% of proximal dissections) 1
• Syncope (present in up to 20% of cases, may occur without typical pain) 1, 2, 3
• Horner's syndrome from compression of superior cervical sympathetic ganglion 1
• Vocal cord paralysis from left recurrent laryngeal nerve compression 1

Limb and End-Organ Ischemia

• Limb ischemia with pulse loss from peripheral vessel obliteration 1, 2
• Leriche's syndrome (bilateral leg pulse loss) if iliac bifurcation is obstructed, typically painless 1
• Paraplegia from sudden intercostal artery involvement 1
• Oliguria or anuria from renal artery involvement 1, 2

Abdominal Signs

• Persistent abdominal pain with elevated acute phase proteins and lactate dehydrogenase suggests celiac artery involvement (8% of cases) or mesenteric artery involvement (8-13% of cases) 1

Atypical Presentations (Critical Pitfalls)

Up to 20% of patients present with syncope alone without typical chest or back pain, and approximately 6.4% present completely painless 2, 3. These atypical presentations include:

• Isolated acute aortic regurgitation with heart failure 3
• Isolated cerebrovascular accident 3
• Incidental abnormal chest radiograph 3
• Superior vena cava syndrome 1
• Hemoptysis or hematemesis from hemorrhage into tracheobronchial tree or esophageal perforation 1
• Signs mimicking pulmonary embolism 1

A critical caveat: Pain resolution does NOT exclude dissection. Re-emergence or change in pain location indicates possible propagation and clinical deterioration, warranting immediate re-evaluation regardless of any pain-free interval 3.

Systematic Examination Approach

When evaluating any patient with sudden severe chest, back, or abdominal pain:

1. Measure blood pressure in both arms simultaneously to detect >20 mmHg systolic differential 1, 6, 3
2. Palpate all peripheral pulses (radial, femoral, dorsalis pedis) bilaterally for deficits 1, 3
3. Auscultate for new aortic regurgitation murmur (diastolic, best heard at left sternal border) 1, 3
4. Perform focused neurologic examination for stroke, altered consciousness, or focal deficits 1
5. Assess for signs of tamponade if syncope occurred 1

Conversely, all patients presenting with acute neurologic complaints should be questioned about chest, back, or abdominal pain and checked for pulse deficits, as dissection-related neurologic pathology patients are less likely to report thoracic pain 1.

Special Populations

Patients under age 40 presenting with sudden severe pain should be specifically questioned and examined for physical features of Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, or Turner syndrome 1. These patients develop dissection at much younger ages than the typical hypertensive population 5.

Urgency

Untreated acute aortic dissection carries mortality of 1-2% per hour, with 75% dying within 2 weeks if left untreated 3, 5, 7. The combination of high-risk historical features with any of the physical examination findings above mandates urgent definitive imaging with CT angiography, transesophageal echocardiography, or MRI 1, 2.