Clinical features

Presentation of aortic dissection is diverse and may overlap with much more common conditions; hence clinicians must maintain a high degree of suspicion (1).

Clinically, presentation of aortic dissection can be divided into two phases:

• interruption of the intima with severe pain and loss of pulse volume
• next step is when the pressure exceeds a critical limit and rupture occurs (2)

The patient typically presents with complains of chest pain:

• sudden and severe pain in the chest, back or abdomen
  • analysis of the International Registry of Acute Dissection (IRAD) noted that
  • type A dissection - frequently presents with severe chest pain, anterior (71%) and posterior (32%)
  • type B - most likely to present with back pain (64%) followed by chest and abdominal pain (63% and 43%, respectively) (3)
  • the pain is described as sharp tearing or stabbing in nature, which may improve slightly over time
    • although classically described as having a tearing or ripping quality, majority of patients are more likely to describe the pain as sharp or stabbing (3)
• pain may be absent in some patients
  • patients on steroids and patients with Marfan syndrome may be more prone to present without pain (3)
• the pain may be migratory or may radiate to the
  • neck - in type A dissection
  • interscapular area - in type B dissection
• myocardial pain may coexist if coronary arteries are involved

Other presenting features may include:

• sweating, pallor and tachycardia
• blood pressure abnormalities
  • more than 20 mmHg blood pressure difference between the two arms
  • hypertension - mostly type B dissections
  • hypotension - mainly in patients with type A (may be normotensive as well)
• a prominent arterial pulsation at the root of the neck
• pulse deficits
• diastolic murmur of aortic regurgitation
• syncope, cerebrovascular accidents and other neurological manifestations
• end organ ischemia e.g. - symptomatic limb ischaemia, or visceral ischaemia (1,2,4)

Reference:

• (1)Braverman AC. Acute aortic dissection: clinician update. Circulation. 2010;122(2):184-8.
• (2) Hebballi R, Swanevelder J. Diagnosis and management of aortic dissection. Contin Educ Anaesth Crit Care Pain (2009) 9 (1): 14-18
• (3) Hiratzka LF et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121(13):e266-369
• (4) Thrumurthy SG et al. The diagnosis and management of aortic dissection. BMJ. 2011;344:d8290.