History and exam

Key diagnostic factors

common

acute severe chest pain

Acute onset of a severe tearing or ripping chest pain suggests aortic dissection.[11][4]​​ 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.[10][14] 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.[10][14][4]​​

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][37]

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.[10][11][4]​​ The deficit may be unilateral or bilateral depending on the level of the intimal flap. Pulse deficits may be present in more distal aortic dissections (e.g., of the descending aorta) and, in some cases, may lead to acute limb ischemia. However, pulse deficits are less common than in more proximal dissections.[10]

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.[38]

hypotension

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

Other diagnostic factors

common

hypertension

Due to pre-existing 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.

Risk factors

strong

hypertension

Most patients have prior hypertension, often poorly controlled.[10][11] The International Registry of Acute Aortic Dissection found that 77% of patients with aortic dissection had a history of hypertension and 27% had a history of atherosclerosis.[12]

atherosclerotic aneurysmal disease

Approximately 1% of sudden deaths are attributable to aortic rupture. Of these, two-thirds are due to dissection and one third to degenerative aneurysms.[13]

Marfan syndrome

Predisposes to both aneurysms and/or dissections, presumably related to weakness of the aortic wall.[4]​​[14][Figure caption and citation for the preceding image starts]: Transesophageal echocardiography (transverse aortic section) showing a circumferential dissection of the ascending aorta in a 30-year-old patient with features of Marfan syndromeBouzas-Mosquera A, Solla-Buceta M, Fojón-Polanco S. Circumferential aortic dissection. BMJ Case Reports 2009; doi:10.1136/bcr.2007.049908 [Citation ends].com.bmj.content.model.Caption@36ff5e4[Figure caption and citation for the preceding image starts]: CT scan showing dissecting aneurysm in a 45-year-old patient with Marfan syndrome experiencing chest painSanyal K, Sabanathan K. Chest pain in Marfan syndrome. BMJ Case Reports 2009; doi:10.1136/bcr.07.2008.0431 [Citation ends].com.bmj.content.model.Caption@1e2a4dbd

Ehlers-Danlos syndrome

Ehlers-Danlos syndrome type IV predisposes to both aneurysms and/or dissections, presumably related to weakness of the aortic wall.[4]​​[14]

bicuspid aortic valve

Predisposes to both aneurysms and/or dissections, presumably related to weakness of the aortic wall.[4]​​

annuloaortic ectasia

Predisposes to both aneurysms and/or dissections, presumably related to weakness of the aortic wall.

coarctation

Untreated coarctation in adults is associated with dissection and is probably related to longstanding hypertension.

smoking

Tobacco use is closely associated with atherosclerotic and vascular disease and therefore dissections.

family history of aortic disease or connective-tissue disorder

Family history confers increased risk.[10][11][15]

weak

older age

The usual presentation is a man in his 50s. However, aortic dissection can occur in younger patients, even in the absence of connective-tissue disorders, and should be considered given the severity of the process.[4]​​

giant cell arteritis

Can weaken the media of the aorta and lead to expansion or dissection.

overlap connective-tissue disorders

Clinical or laboratory features of several connective tissue diseases such as rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, polymyositis, dermatomyositis, and Sjogren syndrome, without meeting the criteria for a specific diagnosis.

surgical/catheter manipulation

Manipulation of at-risk aortas: examples of procedures include cardiac catheterization, aortic valve replacement, or thoracic stent-grafting.[8][11][16]

cocaine/amphetamine use

Acute hypertension, vasoconstriction, increased stroke volume, and vasospasm as a result of the misuse of these agents may lead to aortic dissection. Younger age at presentation is typical.[17]

heavy lifting

Typically confined to young patients and theoretically attributed to the elevated aortic pressure during straining.

pregnancy

Case reports; for example, in conjunction with Marfan syndrome.[18][19]

nondiabetic

One systematic review and meta-analysis found that diabetes is associated with a lower prevalence of aortic dissection and abdominal aortic aneurysm.[20] Data from one observational Swedish study showed that type 2 diabetes reduces the relative risk of aortic dissection by 47% over 7 years.[21] There are some data suggesting that metformin therapy may be responsible for the lower abdominal aortic aneurysm rates seen in adults with diabetes,[22][23] but the potential mechanism is yet to be determined. 

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