History and exam

Key diagnostic factors

common

acute severe chest pain

Acute onset of a severe tearing or ripping chest pain suggests aortic dissection.[15]​ Although this is the classic textbook description of pain in aortic dissection, patients more commonly report the abrupt onset of severe 'sharp' or 'stabbing' pain, maximal at onset.[6]

May change location with time as the dissection extends.[18] Anterior pain is typically associated with dissection of ascending aorta.​

acute severe interscapular and lower back pain

Usually occurs with dissection of the descending aorta.[15]​ Pain may migrate through the thorax or abdomen, and the location of pain may change with time as the dissection extends.[2][18]

left/right blood pressure differential

A blood pressure differential between the two arms is a hallmark of aortic dissection.[6]​ Pulse differences in the lower limbs may also be evident.

pulse deficit

A pulse deficit (reduction or absence of a pulse) is particularly common in a proximal dissection affecting the aortic arch.[2][6][15]​​​ The deficit may be unilateral or bilateral depending on the level of the intimal flap. Pulse deficits may also be present (less commonly) in more distal aortic dissections (e.g., of the descending aorta).[2] In some cases, this may lead to acute limb ischaemia.

diastolic murmur

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

features of Marfan syndrome

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

features of Ehlers-Danlos syndrome

Type IV Ehlers-Danlos syndrome predisposes to both aneurysms and/or dissections.[6]​ Features include translucent skin, easy bruising, hypermobility of small joints, and premature ageing of the skin (acrogeria).[39]

uncommon

syncope

Up to 10% of patients may present with syncope and no pain.[30]

hypotension

Associated with cardiac tamponade and/or hypovolaemic shock.

Other diagnostic factors

common

hypertension

Due to pre-existing hypertensive condition or increased sympathetic drive.

uncommon

dyspnoea

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

altered mental status

Due to cerebral ischaemia.

paraplegia

Due to compromise of intercostal vessels and subsequent spinal cord ischaemia.

hemiparesis/paraesthesia

Due to cerebral or peripheral ischaemia.

abdominal pain

Visceral ischaemia 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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