Diagnostic Approach to Aortic Dissection

Clinical Presentation and Diagnosis

The American College of Cardiology recommends CT angiography (CT-A) of the chest as the definitive diagnostic test to confirm or exclude aortic dissection in patients presenting with chest pain radiating to the back, hypotension, pleural effusion, and left ventricular hypertrophy 1, 2
Chest pain radiating to the back is a classic presentation of aortic dissection, according to the American College of Cardiology and Circulation 1, 2
Hypotension suggests hemodynamic compromise from cardiac tamponade, aortic rupture, or severe aortic regurgitation, as stated by Circulation 2
Pleural effusion can result from hemothorax secondary to aortic rupture, as noted by the American College of Cardiology 1
Left ventricular hypertrophy is a predisposing factor for aortic pathology, particularly in the setting of chronic hypertension, according to Circulation 2

CT angiography is the gold standard for diagnosing acute aortic dissection with sensitivity and specificity exceeding 95%, as recommended by the American College of Cardiology 1
CT-A provides rapid acquisition, definitive visualization of the aortic intimal flap, true and false lumens, assessment of dissection extent and branch vessel involvement, and detection of complications, as stated by the American College of Cardiology and the American College of Radiology 1, 3
The American College of Radiology notes that CT-A can also evaluate for alternative diagnoses if dissection is excluded 4

The American College of Cardiology and Circulation recommend stabilizing hemodynamics while arranging urgent imaging, and ordering CT-A of the chest with IV contrast immediately 1, 2
If CT-A confirms aortic dissection, the American College of Cardiology and Circulation recommend emergency cardiac surgery for Type A dissection and medical management for Type B dissection unless complicated 1, 2
If CT-A excludes aortic dissection, the American College of Cardiology recommends evaluating for alternative diagnoses, such as pulmonary embolism, acute coronary syndrome, pericarditis, or hypertensive emergency 1, 4, 5

Chest pain radiating to the back is the classic presentation of aortic dissection, particularly when the pain has sudden onset with a "ripping" or "tearing" quality, as recommended by the American Heart Association 6
A widened mediastinum on chest x-ray is present in 62.6% of type A and 56% of type B aortic dissections, and when combined with severe pain of abrupt onset and pulse differential, creates >80% probability of dissection, according to the American College of Cardiology 6, 7
Esophageal rupture typically requires a precipitating event, such as forceful vomiting, instrumentation, or trauma, as noted by the American College of Cardiology 7
Additional findings expected in esophageal rupture include subcutaneous emphysema, pneumothorax, and unilateral decreased breath sounds, as reported by the American Heart Association 6, 7

The absence of classic triad does not rule out dissection, even with 0 of 3 high-risk features, 4% of patients still had aortic dissection, as found by the American College of Emergency Physicians 8