Aortic Dissection Presentation and Diagnosis

Pain Characteristics

The American Heart Association notes that Type A dissections (involving the ascending aorta) most frequently present with chest pain (80%), which is more commonly anterior (71%) than posterior (32%) 1, 2
The American College of Cardiology recommends considering Type B dissections (involving only the descending aorta) when patients present with back pain (64%), typically located in the interscapular region 1, 2, 3, 4
Back pain occurs in 47% of Type A dissection cases, typically as a result of antegrade dissection extending into the descending aorta 1, 2
Abdominal pain occurs in 21% of Type A dissection cases and 43% of Type B dissection cases 1, 2

The European Society of Cardiology states that pain of aortic dissection is typically abrupt in onset (84% of cases) and severe in intensity (90% of cases) 5
Pain is often described as sharp or stabbing (51-64%) rather than the classic "tearing" or "ripping" quality 5
The American Heart Association notes that pain may have a migrating quality (12-55% of cases) as the dissection extends 5

The location of pain can help predict the likelihood of aortic dissection being suspected, with both chest and back pain presenting in 86% of suspected cases 1, 2
When only chest pain is present, dissection is suspected in 45% of cases, and when primarily abdominal pain is present, dissection is suspected in only 8% of cases 1, 2

The American College of Cardiology recommends being aware that up to 6.4% of patients with acute aortic dissection present without pain, particularly older patients, patients on steroids, and patients with Marfan syndrome 1, 2
These patients more commonly present with syncope, stroke, or congestive heart failure 1, 2
Other symptoms that may accompany back pain in aortic dissection include syncope (up to 20% of cases), cardiac failure due to aortic regurgitation, pulse deficits or limb ischemia due to vessel obstruction, paraplegia, and oliguria or anuria with renal artery involvement 3, 4, 6

The American Heart Association notes that patients with aortic dissection may present with a new or unknown murmur of aortic insufficiency, and a systolic blood pressure differential between extremities 7
The American College of Cardiology recommends considering aortic dissection in patients with focal neurologic deficits and pain, as well as those with altered mental status, more commonly seen in women 8
Patients with a history of hypertension and cardiovascular disease may not exhibit typical symptoms, requiring increased vigilance 8

The American Heart Association suggests that a d-dimer level >0.5 µg/mL may be a useful laboratory marker, with a sensitivity of 91-100%, but should not be used to rule out aortic dissection 9
The American College of Emergency Physicians notes that an ADD score of 0 is insufficient to exclude aortic dissection, and clinical decision rules should not be used alone to identify low-risk patients 7, 10

The American Heart Association reports that women with aortic dissection are older, less likely to present within the first 6 hours, and have a higher in-hospital mortality rate (30% vs 21% in men) 8
Patients with genetic connective tissue disorders, such as Marfan syndrome, have an increased risk of aortic dissection at a younger age 8

The American College of Emergency Physicians recommends assessing for high-risk predisposing conditions, including Marfan syndrome or other connective tissue disorders, family history of aortic disease, known aortic valve disease, recent aortic manipulation, and known thoracic aortic aneurysm, as these conditions significantly increase dissection risk 11
Patients with a family history of aortic disease are at increased risk of dissection 11
The presence of known aortic valve disease, particularly bicuspid aortic valve, is a high-risk marker for dissection 11
Recent aortic manipulation, such as catheterization or cardiac surgery, increases the risk of dissection 11
Known thoracic aortic aneurysm is a high-risk condition for dissection 11
Pulse deficit, defined as absent or diminished peripheral pulses, is a high-risk examination feature for dissection 11

The American College of Emergency Physicians recommends measuring blood pressure in both arms, obtaining D-dimer if available, and proceeding directly to CT angiography if clinical suspicion persists, even with an ADD score of 0 or negative D-dimer 12, 13
D-dimer >0.5 µg/mL has high sensitivity (91-100%) for dissection, but should not be used alone to rule out dissection 14, 11
False-negative D-dimer results can occur in patients with chronic dissections, thrombosed false lumen, intramural hematoma without intimal flap, short dissection length, or young patients 14, 11
A normal chest X-ray does not exclude dissection, as mediastinal or aortic widening is present in only 62.6% of Type A and 56% of Type B dissections 15, 16

The ADD score algorithm calculates the risk of dissection based on the number of high-risk markers present, with an ADD score of 0 having a 4.3-5.9% risk of dissection, an ADD score of 1 having a 27.3% risk, and an ADD score ≥2 having a 39.1% risk 15
The American College of Emergency Physicians recommends against relying solely on clinical decision rules to identify low-risk patients with suspected aortic dissection, as even patients with an ADD score of 0 still have a significant risk of dissection 12, 11

Marfan syndrome patients are at higher risk for painless presentation of dissection 14
Women with dissection are older at presentation, less likely to present within 6 hours, and have higher in-hospital mortality compared to men 14