Aortic Dissection Presentation and Diagnosis

Clinical Presentation

Aortic dissection most commonly presents with abrupt onset of severe, sharp chest or back pain that is maximal at the time of onset, occurring in up to 90% of patients, though clinicians must remain vigilant for atypical presentations including painless dissection in up to 6.4% of cases 1, 2
The European Heart Journal reports that abrupt onset with maximum intensity at the start occurs in 84% of cases, distinguishing it from myocardial infarction which typically builds gradually 1
Severe intensity is reported in 90% of cases 3
Sharp or stabbing quality is reported in 51-64% of cases rather than the classic "tearing" or "ripping" description 2
Migrating quality is reported in 12-55% of cases as the dissection extends 2
Type A dissections (ascending aorta) typically present with chest pain in 80% of cases, more commonly anterior (71%) than posterior (32%) 2
Back pain occurs in 47% of Type A cases when dissection extends into descending aorta 2
Type B dissections (descending aorta only) typically present with back pain in 64% of cases, typically interscapular 2
Abdominal pain is reported in 43% of Type B cases 2
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, 2, 3

Pulse deficits occur in less than 20% of current patients (historically 50% in older series) 1, 5
Diastolic murmur indicative of aortic regurgitation is reported in approximately 50% of patients 4
Congestive heart failure is reported as the predominant symptom, usually from severe aortic regurgitation 4, 3
Cardiac tamponade resulting in hypotension and syncope is a potential complication 4, 5, 3
Hypertension is typically associated with distal (Type B) aortic dissection 1, 5, 3
Blood pressure differential between arms or between upper and lower extremities is a significant finding 6

Neurological deficits (loss of consciousness, ischemic paresis) occur in up to 40% of patients with proximal dissection 1, 5
Stroke or cerebrovascular accident without pain is a potential complication 1
Paraplegia from sudden separation of intercostal arteries from the aortic lumen is a potential complication 4, 5
Horner's syndrome from compression of the superior cervical sympathetic ganglion is a potential complication 4
Vocal cord paralysis from compression of the left recurrent laryngeal nerve is a potential complication 4, 5

Oliguria or anuria from renal artery involvement is a potential complication 4, 5, 3
Persistent abdominal pain with elevation of acute phase proteins and lactate dehydrogenase indicating celiac artery involvement (8% of cases) is a potential complication 1, 5
Mesenteric artery involvement is reported in 8-13% of cases 1, 5

Hemoptysis or hematemesis from hemorrhage into the tracheobronchial tree or esophageal perforation is a potential complication 4, 5
Superior vena cava syndrome is a potential complication 4, 5
Upper airway obstruction from compression is a potential complication 4
Signs mimicking pulmonary embolism from pulmonary artery compression is a potential complication 4, 5
Leriche's syndrome (painless pulse loss in both legs) from complete iliac bifurcation obstruction is a potential complication 4
High fever from release of pyrogenic substances from the aortic wall, which can persist and be misinterpreted as inflammatory disease is a potential complication 4, 5

The typical patient is a male in his 60s with a history of hypertension presenting with abrupt onset chest pain 1, 5, 3