Aortic dissection history and symptoms: Difference between revisions

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{{Template:Aortic dissection}}
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{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}, {{Sahar}}
==Overview==
==Overview==
67% of patients with [[aortic]] dissection present with [[acute]] [[symptom]]s (<2 weeks), and 33% with [[chronic]] [[symptom]]s (>= 2 weeks). 74% of patients who survive the initial tear typically present with the sudden onset of severe tearing [[pain]].  
History of [[patients]] with aortic dissection may be positive for factors such as [[connective tissue disease]], known [[aortic valve]] disease, recent [[heart surgery]], Known [[thoracic aortic aneurysm]], and family history of the [[aortic]] disease. Sudden onset [[Chest pain|chest]]/[[back pain]] is the most common [[symptom]] of aortic dissection. [[Pain]] may be of sharp, ripping, tearing, and knife-like quality.  
==History and Symptoms ==


==History==
=== History ===
The presence of [[syndrome]]s /diseases or procedures that place the patient at high risk of dissection should be ascertained:
History of [[patients]] with aortic dissection may include the following factors:<ref name="pmid25173340">{{cite journal |vauthors=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ |title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>
* [[Marfan's syndrome]]
 
* [[Connective tissue disease]]
* [[Connective tissue disease]] such as [[Marfan's syndrome]]
* Family history of [[aortic]] disease
* Family history of the [[aortic]] disease
* Known [[aortic valve]] disease such as [[bicuspid aortic valve]] disease
* Known [[aortic valve]] disease such as [[bicuspid aortic valve]] disease
* Recent [[heart surgery]] or [[aortic]] manipulation
* Recent [[heart surgery]] or [[aortic]] manipulation
* Known [[thoracic aortic aneurysm]]
* Known [[thoracic aortic aneurysm]]


==Pain==
===Common Symptoms===
===Chest Pain===
Common [[symptoms]] of aortic dissection include:<ref name="HaganNienaber2000">{{cite journal|last1=Hagan|first1=Peter G.|last2=Nienaber|first2=Christoph A.|last3=Isselbacher|first3=Eric M.|last4=Bruckman|first4=David|last5=Karavite|first5=Dean J.|last6=Russman|first6=Pamela L.|last7=Evangelista|first7=Arturo|last8=Fattori|first8=Rossella|last9=Suzuki|first9=Toru|last10=Oh|first10=Jae K.|last11=Moore|first11=Andrew G.|last12=Malouf|first12=Joseph F.|last13=Pape|first13=Linda A.|last14=Gaca|first14=Charlene|last15=Sechtem|first15=Udo|last16=Lenferink|first16=Suzanne|last17=Deutsch|first17=Hans Josef|last18=Diedrichs|first18=Holger|last19=Marcos y Robles|first19=Jose|last20=Llovet|first20=Alfredo|last21=Gilon|first21=Dan|last22=Das|first22=Sugata K.|last23=Armstrong|first23=William F.|last24=Deeb|first24=G. Michael|last25=Eagle|first25=Kim A.|title=The International Registry of Acute Aortic Dissection (IRAD)|journal=JAMA|volume=283|issue=7|year=2000|pages=897|issn=0098-7484|doi=10.1001/jama.283.7.897}}</ref><ref>{{cite journal|title=Correspondence|journal=The Annals of Thoracic Surgery|volume=67|issue=2|year=1999|pages=593|issn=00034975|doi=10.1016/S0003-4975(99)00037-5}}</ref><ref name="pmid22456637">{{cite journal |vauthors=Trimarchi S, Tolenaar JL, Tsai TT, Froehlich J, Pegorer M, Upchurch GR, Fattori R, Sundt TM, Isselbacher EM, Nienaber CA, Rampoldi V, Eagle KA |title=Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD |journal=J Cardiovasc Surg (Torino) |volume=53 |issue=2 |pages=161–8 |date=April 2012 |pmid=22456637 |doi= |url=}}</ref><ref name="pmid11980527">{{cite journal |vauthors=Klompas M |title=Does this patient have an acute thoracic aortic dissection? |journal=JAMA |volume=287 |issue=17 |pages=2262–72 |date=May 2002 |pmid=11980527 |doi=10.1001/jama.287.17.2262 |url=}}</ref>
92% of patients with [[anterior]] [[chest pain]] as their major source of [[pain]] have either type I or type II dissections, and only 8% have type III. In 17% patients, the [[pain]] migrates as dissection extends down the [[aorta]].


===Neck, Throat, and Jaw Pain===
*[[Chest pain]] (especially migrating pain)
Neck, throat, jaw, and [[unilateral]] face [[pain]] are also seen more commonly in those with type I or type II dissection.
**Sudden onset of pain is the most common [[symptom]].
**The quality of [[pain]] is different from other causes of [[chest pain]]. it may be sharp, ripping, tearing, and knife-like.
**The most common site of [[pain]] in order of frequency is [[Chest pain|chest]] (80%), [[Back pain|back]] (40%), and [[Abdominal pain|abdomen]] (25%).
**Type A aortic dissection more commonly presents with [[chest pain]], whereas type B tends to manifest with [[Back pain|back]]/[[abdominal pain]].
*[[Neck pain|Neck]], throat, and [[jaw pain]]
*[[Back pain]]
*[[Pleuritic pain]] (maybe suggestive of [[acute pericarditis]] due to [[hemorrhage]] into the [[pericardial sac]].


===Back Pain===
* It worth mentioning that the presence of [[pain]] is not necessary for the [[diagnosis]] of aortic dissection. [[Patients]] may present with [[syncope]], [[stroke]] or [[symptoms]] suggestive of [[congestive heart failure|congestive heart failure (CHF)]].
52% of patients with type III dissection have the majority of their [[pain]] in the back, and 67% of these patients have some degree of back [[pain]].


===Pleuritic Pain===
===Less Common Symptoms===
[[Pleuritic pain]] suggests acute [[pericarditis]] associated with [[hemorrhage]] into the [[pericardial sac]].
Less common [[symptoms]] of aortic dissection include:<ref name="pmid25173340">{{cite journal |vauthors=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ |title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>


===Painless Dissection===
* [[Abdominal pain]] following [[mesenteric ischemia]]
Up to 15 – 55 % of patients can have painless dissection. Dissection should therefore be included in the differential in patients with unexplained syncope, stroke or congestive heart failure (CHF).
* [[Cardiac arrest]] (rarely)
* [[Claudication]] due to [[iliac artery]] involvement
* Symptoms of [[congestive heart failure]] may be observed due to [[aortic root]] [[dilatation]] leading to [[aortic insufficiency]]
* [[Dysphagia]] due to compression of the [[esophagus]]
* [[Hemoptysis]] due to compression of and erosion into the [[bronchus]]
* [[Horner syndrome]] due to compression of the [[superior cervical ganglia]]
* [[Oliguria]]/ [[Anuria]] due to involvement of the [[renal arteries]] causing pre-[[renal]] [[azotemia]].
* [[Paraplegia]], [[paralysis]] from involvement of one of the [[cerebral artery|cerebral]] or [[spinal cord|spinal]] [[artery|arteries]]
* [[Stridor]] and [[wheezing]] due to compression of the airway
* [[Swelling]] of the neck and face due to compression of the [[superior vena cava]] or [[Superior vena cava syndrome]]
* [[Syncope]]
* [[Upper gastrointestinal bleed|Upper gastrointestinal (UGI) bleed]]
* [[hoarseness]] (compression of the [[recurrent laryngeal nerve]])
===History and Symptoms Associated with High Pretest Probability of Aortic Dissection<ref name="pmid25173340">{{cite journal |vauthors=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ |title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:Blue"|[[ESC guidelines classification scheme#Classification of Recommendations|History]]
|-
|bgcolor="LightBlue" |
*[[Connective tissue disorders]] including [[Marfan syndrome]]
* Family history of [[aortic]] disease
* Personal history [[aortic valve disease]]
* Personal history of [[thoracic aortic aneurysm]]
* Previous [[aortic]] surgery (including [[cardiac surgery]])
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:Blue"|[[ESC guidelines classification scheme#Classification of Recommendations|Symptoms]]
|-
|bgcolor="LightBlue" |
*[[Chest pain|Chest]], [[Back pain|back]], or [[abdominal pain]] with at least one of the following features:
** Abrupt onset
** Severe intensity
** Ripping or tearing
|}


==Infrequent Symptoms==
== 2022 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease<ref name="pmid36334952">{{cite journal| author=Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume=  | issue=  | pages=  | pmid=36334952 | doi=10.1016/j.jacc.2022.08.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=36334952  }}</ref> ==
* [[Abdominal pain]] due to mesenteric ischemia
{| class="wikitable"
* [[Cardiac arrest]] occurs in 4% of patients
|+Signs and Symptoms of AAS
* [[Claudication]] due to [[iliac artery]] occlusion
!Clinical Signs and Symptoms
* [[Congestive heart failure]] may be observed due to aortic root dilatation leading to [[aortic insufficiency]]
!Cause
*[[Dysphagia]] due to compression of the [[esophagus]]
|-
*[[Hemoptysis]] due to compression of and erosion into the [[bronchus]]
|Asymmetric blood pressure (>20 mm Hg) between limbs
*[[Horner syndrome]] due to compression of the [[superior cervical ganglia]]
|Compromise of branch artery flow
* [[Oliguria]]/ [[Anuria]] due to involvement of the [[renal arteries]] causing [[pre-renal azotemia]].<ref>Saner, H.E., et al., Aortic dissection presenting as Pericarditis. Chest, 1987. 91(1): p. 71-4. PMID 3792088</ref> <ref>Rosman, H.S., et al., Quality of history taking in patients with aortic dissection. Chest, 1998. 114(3): p. 793-5. PMID 9743168</ref> <ref>Hagan, P.G., et al., The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 2000. 283(7): p. 897-903. PMID 10685714</ref> <ref>von Kodolitsch, Y., A.G. Schwartz, and C.A. Nienaber, Clinical prediction of acute aortic dissection. Arch Intern Med, 2000. 160(19): p. 2977-82. PMID 11041906</ref>
|-
* [[Paraplegia]], [[paralysis]] from involvement of one of the cerebral or spinal arteries
|Bowel ischemia or gastrointestinal bleed
*[[Stridor]] and [[wheezing]] due to compression of the airway
|Malperfusion of the celiac or superior mesenteric artery
*Swelling of the neck and face due to compression of the superior vena cava or [[Superior vena cava syndrome]]
|-
* [[Syncope]] may occur and in 50% of cases, the etiology of the syncope is hemorrhage into the pericardial sac causing [[pericardial tamponade]]
|Dysphagia
* Upper gastrointestinal (UGI) bleed
|Compression of the esophagus
*[[Vocal cord paralysis]] and [[hoarseness]] (compression of the [[recurrent laryngeal nerve]])
|-
|Dyspnea
|Compression of trachea or bronchus, congestive heart failure from aortic regurgitation, or cardiac tamponade
|-
|Hemoptysis
|Vascular rupture into lung parenchyma
|-
|Hoarseness
|Compression recurrent laryngeal nerve
|-
|Horner’s syndrome
|Compression of sympathetic chain
|-
|Myocardial ischemia or myocardial infarction
|Coronary artery involvement by dissection or compression by aneurysm
|-
|New murmur of aortic regurgitation
|Incomplete aortic valve closure secondary to leaflet tethering by the dilated aorta or cusp prolapse because of dissection into the aortic root
|-
|Oliguria or hematuria (gross)
|Malperfusion of 1 or both renal arteries
|-
|Paraplegia
|Spinal malperfusion attributable intercostal artery involvement
|-
|Lower extremity ischemia
|Malperfusion of iliac artery
|-
|Shock
|Cardiac tamponade, hemothorax, frank aortic rupture, acute severe aortic regurgitation, severe myocardial ischemia
|-
|Shortness of breath
|Pericardial effusion, congestive heart failure from acute severe aortic regurgitation, or hemothorax
|-
|Stroke symptoms
|Carotid or vertebral artery involved
|-
|Superior vena cava syndrome
|Compression of the superior vena cava
|-
|Syncope
|Carotid artery involvement or cardiac tamponade
|}
AAS indicates acute aortic syndrome
 
==2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases<ref name="pmid25173340">{{cite journal |vauthors=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ |title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>==
===Clinical Assessment of Patients Suspicious of Aortic Dissection<ref name="pmid25173340">{{cite journal |vauthors=Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ |title=2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>In all patients with suspected AAS, pre-test probability assessment is recommended, according to the patient’s condition, symptoms, and clinical features.<ref name="EvangelistaIsselbacher2018">{{cite journal|last1=Evangelista|first1=Arturo|last2=Isselbacher|first2=Eric M.|last3=Bossone|first3=Eduardo|last4=Gleason|first4=Thomas G.|last5=Eusanio|first5=Marco Di|last6=Sechtem|first6=Udo|last7=Ehrlich|first7=Marek P.|last8=Trimarchi|first8=Santi|last9=Braverman|first9=Alan C.|last10=Myrmel|first10=Truls|last11=Harris|first11=Kevin M.|last12=Hutchinson|first12=Stuart|last13=O’Gara|first13=Patrick|last14=Suzuki|first14=Toru|last15=Nienaber|first15=Christoph A.|last16=Eagle|first16=Kim A.|title=Insights From the International Registry of Acute Aortic Dissection|journal=Circulation|volume=137|issue=17|year=2018|pages=1846–1860|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031264}}</ref>''([[ESC guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=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. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>==
==2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease (DO NOT EDIT)<ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=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. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>==
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' For patients presenting with a history of acute cardiac and noncardiac symptoms associated with a significant likelihood of thoracic aortic disease, the clinician should perform a focused physical examination, including a careful and complete search for arterial perfusion differentials in both upper and lower extremities, evidence of visceral [[ischemia]], focal neurological deficits, a [[murmur]] of [[aortic regurgitation]], [[bruit]]s, and findings compatible with possible [[cardiac tamponade]].<ref>Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery. 18th ed. Philadelphia: Elsevier Health Sciences, 2008.</ref><ref>Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: 2007.</ref><ref>Isselbacher E. Cecil Medicine. 23rd ed. Philadelphia: Elsevier Health Sciences, 2008.</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>  
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' For patients presenting with a history of [[acute]] [[cardiac]] and non[[cardiac]] [[symptom]]s associated with a significant likelihood of [[thoracic aorta|thoracic aortic]] disease, the clinician should perform a focused physical examination, including a careful and complete search for [[artery|arterial]] [[perfusion]] differentials in both upper and lower extremities, evidence of [[visceral]] [[ischemia]], focal [[neurological]] deficits, a [[murmur]] of [[aortic regurgitation]], [[bruit]]s, and findings compatible with possible [[cardiac tamponade]].<ref>Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery. 18th ed. Philadelphia: Elsevier Health Sciences, 2008.</ref><ref>Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: 2007.</ref><ref>Isselbacher E. Cecil Medicine. 23rd ed. Philadelphia: Elsevier Health Sciences, 2008.</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}
== References ==
== References ==
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{{Reflist|2}}
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[[Category:Emergency medicine]]
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[[Category:Up-To-Date]]
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Latest revision as of 01:58, 4 December 2022

Aortic dissection Microchapters

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Case #1


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Sahar Memar Montazerin, M.D.[3]

Overview

History of patients with aortic dissection may be positive for factors such as connective tissue disease, known aortic valve disease, recent heart surgery, Known thoracic aortic aneurysm, and family history of the aortic disease. Sudden onset chest/back pain is the most common symptom of aortic dissection. Pain may be of sharp, ripping, tearing, and knife-like quality.

History and Symptoms

History

History of patients with aortic dissection may include the following factors:[1]

Common Symptoms

Common symptoms of aortic dissection include:[2][3][4][5]

Less Common Symptoms

Less common symptoms of aortic dissection include:[1]

History and Symptoms Associated with High Pretest Probability of Aortic Dissection[1]

History
Symptoms
  • Chest, back, or abdominal pain with at least one of the following features:
    • Abrupt onset
    • Severe intensity
    • Ripping or tearing

2022 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease[6]

Signs and Symptoms of AAS
Clinical Signs and Symptoms Cause
Asymmetric blood pressure (>20 mm Hg) between limbs Compromise of branch artery flow
Bowel ischemia or gastrointestinal bleed Malperfusion of the celiac or superior mesenteric artery
Dysphagia Compression of the esophagus
Dyspnea Compression of trachea or bronchus, congestive heart failure from aortic regurgitation, or cardiac tamponade
Hemoptysis Vascular rupture into lung parenchyma
Hoarseness Compression recurrent laryngeal nerve
Horner’s syndrome Compression of sympathetic chain
Myocardial ischemia or myocardial infarction Coronary artery involvement by dissection or compression by aneurysm
New murmur of aortic regurgitation Incomplete aortic valve closure secondary to leaflet tethering by the dilated aorta or cusp prolapse because of dissection into the aortic root
Oliguria or hematuria (gross) Malperfusion of 1 or both renal arteries
Paraplegia Spinal malperfusion attributable intercostal artery involvement
Lower extremity ischemia Malperfusion of iliac artery
Shock Cardiac tamponade, hemothorax, frank aortic rupture, acute severe aortic regurgitation, severe myocardial ischemia
Shortness of breath Pericardial effusion, congestive heart failure from acute severe aortic regurgitation, or hemothorax
Stroke symptoms Carotid or vertebral artery involved
Superior vena cava syndrome Compression of the superior vena cava
Syncope Carotid artery involvement or cardiac tamponade

AAS indicates acute aortic syndrome

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases[1]

Clinical Assessment of Patients Suspicious of Aortic Dissection[1]

Class I
"In all patients with suspected AAS, pre-test probability assessment is recommended, according to the patient’s condition, symptoms, and clinical features.[7](Level of Evidence: B)"

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease (DO NOT EDIT)[8]

History and Physical Examination for Thoracic Aortic Disease (DO NOT EDIT)[8]

Class I
"1. For patients presenting with a history of acute cardiac and noncardiac symptoms associated with a significant likelihood of thoracic aortic disease, the clinician should perform a focused physical examination, including a careful and complete search for arterial perfusion differentials in both upper and lower extremities, evidence of visceral ischemia, focal neurological deficits, a murmur of aortic regurgitation, bruits, and findings compatible with possible cardiac tamponade.[9][10][11] (Level of Evidence: C)"

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
  2. ↑ Hagan, Peter G.; Nienaber, Christoph A.; Isselbacher, Eric M.; Bruckman, David; Karavite, Dean J.; Russman, Pamela L.; Evangelista, Arturo; Fattori, Rossella; Suzuki, Toru; Oh, Jae K.; Moore, Andrew G.; Malouf, Joseph F.; Pape, Linda A.; Gaca, Charlene; Sechtem, Udo; Lenferink, Suzanne; Deutsch, Hans Josef; Diedrichs, Holger; Marcos y Robles, Jose; Llovet, Alfredo; Gilon, Dan; Das, Sugata K.; Armstrong, William F.; Deeb, G. Michael; Eagle, Kim A. (2000). "The International Registry of Acute Aortic Dissection (IRAD)". JAMA. 283 (7): 897. doi:10.1001/jama.283.7.897. ISSN 0098-7484.
  3. ↑ "Correspondence". The Annals of Thoracic Surgery. 67 (2): 593. 1999. doi:10.1016/S0003-4975(99)00037-5. ISSN 0003-4975.
  4. ↑ Trimarchi S, Tolenaar JL, Tsai TT, Froehlich J, Pegorer M, Upchurch GR, Fattori R, Sundt TM, Isselbacher EM, Nienaber CA, Rampoldi V, Eagle KA (April 2012). "Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD". J Cardiovasc Surg (Torino). 53 (2): 161–8. PMID 22456637.
  5. ↑ Klompas M (May 2002). "Does this patient have an acute thoracic aortic dissection?". JAMA. 287 (17): 2262–72. doi:10.1001/jama.287.17.2262. PMID 11980527.
  6. ↑ Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW; et al. (2022). "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. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check |pmid= value (help).
  7. ↑ Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.
  8. ↑ 8.0 8.1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). "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. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.
  9. ↑ Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery. 18th ed. Philadelphia: Elsevier Health Sciences, 2008.
  10. ↑ Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: 2007.
  11. ↑ Isselbacher E. Cecil Medicine. 23rd ed. Philadelphia: Elsevier Health Sciences, 2008.

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