Aortic dissection history and symptoms

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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

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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

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### History

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

* Connective tissue disease such as Marfan's syndrome
* Family history of the aortic disease
* Known aortic valve disease such as bicuspid aortic valve disease
* Recent heart surgery or aortic manipulation
* Known thoracic aortic aneurysm

### Common Symptoms

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

* Chest pain (especially migrating pain)
* 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 (80%), back (40%), and abdomen (25%).
* Type A aortic dissection more commonly presents with chest pain, whereas type B tends to manifest with back/abdominal pain.
* Neck, throat, and jaw pain
* Back pain
* Pleuritic pain (maybe suggestive of acute pericarditis due to hemorrhage into the pericardial sac.

* 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 (CHF).

### Less Common Symptoms

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Less common symptoms of aortic dissection include:[1]

* Abdominal pain following mesenteric ischemia
* 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 or spinal 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 (UGI) bleed
* hoarseness (compression of the recurrent laryngeal nerve)

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

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History

* 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)

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]

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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]

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### Clinical Assessment of Patients Suspicious of Aortic Dissection[1]

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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]

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

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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

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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).CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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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