Aortic dissection

Case history

A 59-year-old man presents to the accident and emergency department with a sudden onset of excruciating chest pain, which he describes as 'stabbing'. He has a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.

Other presentations

The pain of aortic dissection usually manifests as acute, tearing chest and back pain (Stanford Type A) or tearing back pain (Stanford Type B). It may also migrate through the thorax or abdomen. Although the classic textbook description is of acute 'tearing' or 'ripping' pain, patients more commonly report the abrupt onset of severe 'sharp' or 'stabbing' pain, maximal at onset.[6]Writing Committee Members, Isselbacher EM, Preventza O, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 Dec 13;80(24):e223-393. http://www.ncbi.nlm.nih.gov/pubmed/36334952?tool=bestpractice.com

Symptoms of stroke or visceral or acute limb ischaemia may be present. Patients may be haemodynamically stable or in hypovolaemic shock. Occasionally, depressed mental status or neurological changes, limb pain, paraesthesias or weakness, paraplegia, or syncope are presenting symptoms. Infrequently (less than 10%), patients present atypically without pain.[7]Ayrik C, Cece H, Aslan O, et al. Seeing the invisible: painless aortic dissection in the emergency setting. Emerg Med J. 2006 Mar;23(3):e24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464426 http://www.ncbi.nlm.nih.gov/pubmed/16498148?tool=bestpractice.com There may be signs of heart failure, cardiac tamponade, or a left pleural effusion. Younger patients can present with a recent history of heavy lifting or cocaine use.

Patients with connective-tissue disorders such as Marfan syndrome often present in their 30s, most commonly due to aortic root enlargement. Patients with Marfan syndrome with a normal diameter aorta may also be at risk.[6]Writing Committee Members, Isselbacher EM, Preventza O, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 Dec 13;80(24):e223-393. http://www.ncbi.nlm.nih.gov/pubmed/36334952?tool=bestpractice.com ​​

[Figure caption and citation for the preceding image starts]: Trans-oesophageal echocardiography (transverse aortic section) showing a circumferential dissection of the ascending aorta in a 30-year-old patient with features of Marfan's syndromeBouzas-Mosquera A, Solla-Buceta M, Fojón-Polanco S. Circumferential aortic dissection. BMJ Case Reports 2009; doi:10.1136/bcr.2007.049908 [Citation ends].[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 pain [Citation ends].