History and exam

Key diagnostic factors

common

acute severe chest pain

Acute onset of a severe tearing or ripping chest pain suggests aortic dissection.[4][11] Although this is the the classic textbook description of pain in aortic dissection, patients more commonly describe the pain as severe “sharp” or “stabbing”, maximal at onset.[4]

Pain may migrate through the thorax or abdomen, and the location of pain may change with time as the dissection extends.[13] Anterior pain occurs with dissection of ascending aorta.

acute severe interscapular and lower back pain

Occurs with dissection of the descending aorta.[11] Pain may migrate through the thorax or abdomen, and the location of pain may change with time as the dissection extends.[4][13]

features of Marfan syndrome

Patients may exhibit typical marfanoid features including tall stature, arachnodactyly, pectus excavatum, hypermobile joints, high-arched palate, and narrow face.[10][11]

features of Ehlers-Danlos syndrome

Vascular (type IV) Ehlers-Danlos syndrome predisposes to both aneurysms and/or dissections.[4] Features include translucent skin, easy bruising, hypermobility of small joints, and premature aging of the skin (acrogeria).[10][11][36]

left/right blood pressure differential

A difference in systolic blood pressure of greater than 20 mmHg between the two arms is a key sign of aortic dissection.[4]

pulse deficit

A pulse deficit (reduction or absence of a pulse) is particularly common in a proximal dissection affecting the aortic arch.[4][11]

diastolic murmur

Crescendo pattern, indicating aortic incompetence. Common in proximal dissections, but uncommon in distal dissections.

uncommon

syncope

Up to 10% of patients may present with syncope and no pain.[37]

hypotension

Associated with cardiac tamponade and/or hypovolemic shock.[4]

Other diagnostic factors

common

hypertension

Due to preexisting hypertensive condition or increased sympathetic drive.

uncommon

dyspnea

May indicate new-onset heart failure because of acute aortic insufficiency during proximal dissections, or cardiac tamponade.

altered mental status

Due to cerebral ischemia.

paraplegia

Due to compromise of intercostal vessels and subsequent spinal cord ischemia.[4]

hemiparesis/paresthesia

Due to cerebral or peripheral ischemia.

abdominal pain

Visceral ischemia resulting from compromised organ perfusion.

limb pain/pallor

Due to compromised limb perfusion.

left-sided decreased breath sounds/dullness

Left pleural effusion.

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