[…] radiating to the back, however, dissection may occur anywhere along the aorta and thus the presentation may be broad and mimic other common disorders Variant presentations include: Patients with symptoms above and below the diaphragm Chest pain or back [coreem.net]

We present a case of aortic dissection with an atypical presentation in a peritoneal dialysis patient, and the challenges met with peritoneal dialysis. [ncbi.nlm.nih.gov]

Three of the 10 presented as the sudden onset of fatal electromechanical dissociation, 6 presented with hypotension, and 1 was normotensive on presentation. [doi.org]

• Severe Pain

  PAIN: Severe pain is the #1 symptom. Seek immediate emergency medical care for a sudden onset of severe pain in the chest, stomach, back or neck. The pain is likely to be sharp, tearing, ripping, moving. [johnritterfoundation.org]

  […] radiates to back AND Pulse deficit or difference in upper extremity Blood Pressure >20 mmHg AND Mediastinal Widening or aortic knob widening on Chest XRay Timing Sudden onset: 85% Severity Severe pain: 90% Characteristics Pain: 95% Type A: 94% Type B [fpnotebook.com]

  […] ischaemia and acute kidney injury. [ 1 ] Aortic dissection often presents in two phases: After a first event with severe pain and pulse loss, the bleeding stops. [patient.info]

• Congestive Heart Failure

  If that rupture into the heart leads to congestive heart failure, which is a common sequela, the congestive heart failure might take a couple of days after that to develop. [thehorse.com]

  Congestive heart failure, myocardial infarction and bacterial endocarditis were other cardiac causes of death. In patients with early aortic changes treatment with propranolol or reserpine is suggested. [oadoi.org]

  Sutter offers the widest array of heart-related services in Northern California, including expert diagnosis and treatment for heart attacks, congenital cardiac defects, congestive heart failure, valve conditions, heart arrhythmias, and circulation problems [checksutterfirst.org]

  As the recent deaths of actors Carrie Fisher and Alan Thicke due to heart events remind us, cardiovascular disease is the leading cause of death in this country, but heart attacks, cardiac arrest and congestive heart failure aren’t the only threats. [nbcwashington.com]

• Hypothermia

  Cardiovascular surgical procedures requiring hypothermia present a unique challenge for these patients, requiring modification of the conduct of cardiopulmonary bypass and cardioplegia. [ncbi.nlm.nih.gov]

  A series of patients with type B dissections demonstrated that aggressive use of distal perfusion, CSF drainage, and hypothermia with circulatory arrest improves early mortality and long-term survival rates. [emedicine.medscape.com]

• Pleural Effusion

  Left pleural effusion is common. [merckmanuals.com]

  IMH thickness > 2 cm - Pericardial effusion (to less extend pleural effusion) IMH may persist or evolve into aneurysm or PAU Associated PAU - worse prognostic outcome On the left a Intramural hematoma, hyperdense on a NECT. Same case. [radiologyassistant.nl]

  Pleural effusions, more commonly in descending aortic dissections, and typically left sided. [en.wikipedia.org]

  effusion (L>R), tracheal shift, left apical cap, deviated NGT. [lifeinthefastlane.com]

• Dyspnea

  We recently encountered a case of a patient with PAoD presenting with dyspnea; the clue to diagnosis was the presence of a loud aortic diastolic murmur. [ncbi.nlm.nih.gov]

  […] often sudden pain in the chest ( angina ), shoulders, back, abdomen, arms, neck, hips, or legs Stroke-like symptoms Difficulty swallowing Sweating Anxiety Decreased sensation Nausea Pale skin (pallor) Rapid heart rate (tachycardia) Shortness of breath (dyspnea [utswmedicine.org]

• Hemoptysis

  […] patients Syncope Cerebrovascular accident (CVA) symptoms (eg, hemianesthesia, and hemiparesis, hemiplegia) [1] Altered mental status Numbness and tingling, pain, or weakness in the extremities Horner syndrome (ie, ptosis, miosis, anhidrosis) Dyspnea Hemoptysis [emedicine.medscape.com]

• Regurgitation

  Delayed aortic regurgitation following Valsalva sinus re-dissection is a well-known complication that can occur at any time after surgery for type-A aortic dissection without root replacement. [ncbi.nlm.nih.gov]

  An aortic diastolic murmur occurs in 50% due to aortic regurgitation. Wide pulse pressure may be absent. After a period of pain, cardiac failure may result from gross aortic regurgitation. Cardiac tamponade can cause hypotension and syncope. [patient.info]

  A murmur of aortic regurgitation is heard in about 50% of patients with proximal dissection. Peripheral signs of aortic regurgitation may be present. Rarely, heart failure results from severe acute aortic regurgitation. [merckmanuals.com]

  […] aortic rupture aortic regurgitation acute myocardial infarction cardiac tamponade end-organ ischaemia (brain, limbs, spine, renal, gut, liver) death INVESTIGATIONS Bedside ECG normal inferior ST elevation (right coronary dissection) but can be any STEMI [lifeinthefastlane.com]

• Abdominal Pain

  Abstract A 52-year-old man presented with sudden abdominal pain and intermittent vomiting. [ncbi.nlm.nih.gov]

  98% Sharp pain: 64% Tearing/ripping: 50% Type A: 49% Type B: 52% Distribution: Typically involves both above and below the diaphragm Anterior Chest Pain : 61% Type A: 71% Type B: 44% Back pain: 53% Type A: 46% Type B: 64% Abdominal Pain : 35% Type A [fpnotebook.com]

  They include: Sudden severe chest or upper back pain, often described as a tearing, ripping or shearing sensation, that radiates down the back Loss of consciousness (fainting) Abdominal pain Sudden onset of leg pain with compromised blood flow Which diagnostic [inovaheart.org]

• Nausea

  We report a previously healthy 58-years old female, admitted because of nausea, dizziness, somnolence, a left-sided hemiparesis and arterial hypotension. The electrocardiogram showed atrial fibrillation with ST-elevations and ST-depressions. [ncbi.nlm.nih.gov]

  Symptoms are caused by a decrease of blood flowing to the rest of the body, and can include: Anxiety and a feeling of doom Fainting or dizziness Heavy sweating (clammy skin) Nausea and vomiting Pale skin ( pallor ) Rapid, weak pulse Shortness of breath [nlm.nih.gov]

  Additional symptoms may include the following: Anxiety Difficulty swallowing Dizziness or fainting Nausea and vomiting Pain in the abdomen Pale skin Rapid, weak pulse Shortness of breath or trouble breathing when lying flat Stroke-like symptoms Sweating [houstonmethodist.org]

  […] accident or a gunshot wound Symptoms of aortic dissection can include: Severe, often sudden pain in the chest ( angina ), shoulders, back, abdomen, arms, neck, hips, or legs Stroke-like symptoms Difficulty swallowing Sweating Anxiety Decreased sensation Nausea [utswmedicine.org]

  There may be associated nausea, sweating, shortness of breath, and weakness. The patient may pass out (syncope). [medicinenet.com]

• Hypertension

  KEYWORDS: Cardiovascular System; Drug Misuse (including Addiction); Hypertension [ncbi.nlm.nih.gov]

  Inability to control hypertension with medication is also an indication for surgery in patients with a distal thoracic aortic dissection. Patients with a distal dissection are usually hypertensive, emphysematous, or older. [emedicine.medscape.com]

  Risk factors Approximately 50-75% of patients with dissection will have evidence of hypertension or a previous diagnosis. [ 2 ] Other risk factors include smoking and raised cholesterol. The most common risk factor is hypertension. [patient.info]

• Chest Pain

  pain + vomiting Chest pain or back pain with neurologic findings (may be due to dissection into the carotid arteries) Cardiac tamponade Any patient that generally “looks bad” Only 49% of AD patients have the classic tearing chest pain Presenting blood [coreem.net]

  We present a case of a young recreational cocaine user with uncontrolled hypertension who presented to hospital with acute chest pain and was diagnosed with an acute aortic dissection. The patient's last use of powdered cocaine was 3 days prior. [ncbi.nlm.nih.gov]

  In most cases, the symptoms begin suddenly, and include severe chest pain. The pain may feel like a heart attack. Pain can be described as sharp, stabbing, tearing, or ripping. [nlm.nih.gov]

• Tachycardia

  “The first thing you have to do is correct the ventricular tachycardia,” says Reef. [thehorse.com]

  To control pain (which can contribute to hypertension and tachycardia), expect to administer morphine sulfate. [americannursetoday.com]

  […] dissection can include: Severe, often sudden pain in the chest ( angina ), shoulders, back, abdomen, arms, neck, hips, or legs Stroke-like symptoms Difficulty swallowing Sweating Anxiety Decreased sensation Nausea Pale skin (pallor) Rapid heart rate (tachycardia [utswmedicine.org]

  GTN, labetalol, SNP) start b-blocker first to avoid increased aortic wall stress from reflex tachycardia call cardiothoracic surgeon Indications for surgery Persistent pain Type A Branch Occlusion Leak Continued extension despite optimal medical management [lifeinthefastlane.com]

  Vasodilators such as sodium nitroprusside can be considered for patients with ongoing hypertension, but they should never be used alone, as they generally cause reflex tachycardia. Clinical Team Michael S. Conte, M.D. [vascular.surgery.ucsf.edu]

• Retrosternal Chest Pain

  retrosternal chest pain – anterior dissection interscapular pain – descending aorta severe pain (‘worst ever-pain’) (90%) sudden onset (90%) sharp (64%) or tearing (50%) migrating pain (16%) down the back (46%) maximal at onset ( not crescendo build up [lifeinthefastlane.com]

• Ulcer

  Abstract Rarely, penetrating atherosclerotic ulcers can rupture into the wall of the aorta, resulting in acute aortic dissection. [ncbi.nlm.nih.gov]

  Penetrating atheromatous ulcer involving the ascending aorta is uncommon; however, the ulcer usually ruptures and is commonly lethal. [dx.doi.org]

  Often a precursor to dissection Perforating ulcer- ulcer formation due to atherosclerosis which can lead to intramural thrombus, dissection or aortic perforation (Cline 2012) History + Physical Classic presentation: sudden onset of tearing chest pain [coreem.net]

  Key words: aortic dissection, acute aortic syndromes, intramural hematoma, penetrating atherosclerotic ulcer, Marfan syndrome, connective tissue disorders, TEVAR [web.archive.org]

• Back Pain

  Even in the absence of chest or back pain, the initial urgent care doctor needs to immediately perform chest contrast CT if suspecting aortic dissection from blood pressure laterality or upper mediastinal widening on chest X-ray. [ncbi.nlm.nih.gov]

  pain + vomiting Chest pain or back pain with neurologic findings (may be due to dissection into the carotid arteries) Cardiac tamponade Any patient that generally “looks bad” Only 49% of AD patients have the classic tearing chest pain Presenting blood [coreem.net]

• Flank Pain

  METHODS: We included consecutive adult patients presenting to two tertiary academic care emergency departments over one calendar year presenting with non-traumatic chest, back, abdominal, or flank pain. [ncbi.nlm.nih.gov]

  Symptoms Location of Pain: Chest pain Back pain Flank pain Abdominal pain Leg pain Quality of Pain Pain that is tearing or sharp Abrupt onset of pain Pain that migrates or radiates Neurological Deficits Coma/Altered consciousness Paralysis Extremity numbness [vascularcures.org]

  as in an AMI) Other features end-organ symptoms: neurological, syncope, seizure, limb paraesthesias, pain or weakness, flank pain, SOB + haemoptysis aortic regurgitation hypertension most have ischaemic heart disease Atypical presentations are common [lifeinthefastlane.com]

  Often the aneurysm is first identified when the patient presents with a complaint such as flank pain and assumes they have a kidney stone. [emsworld.com]

  (eg, hemianesthesia, and hemiparesis, hemiplegia) [1] Altered mental status Numbness and tingling, pain, or weakness in the extremities Horner syndrome (ie, ptosis, miosis, anhidrosis) Dyspnea Hemoptysis Dysphagia Flank pain (with renal artery involvement [emedicine.medscape.com]

• Paresis

  Monitoring for limb ischemia via peripheral pulses and cyanosis, limb weakness or paresis, or continued pain is worrisome for a complicated type B dissection requiring surgical intervention. C. [clinicaladvisor.com]

  Both patients showed no pure TGA, but showed TGA-plus-syndrome with additional focal neurological signs such as mild left-side motor deficit, slight anisocoria, and mild facial paresis; therefore, they were classified as having ischemic stroke. [dx.doi.org]

• Limb Weakness

  […] discrepancy caused by an occluded vessel – check BP in the arm with best radial pulse) shock – ominous signs: tamponade, hypovolaemia, vagal tone heart failure neurological deficits: limb weakness, paraesthesiae, Horners syndrome SVC syndrome – compression [lifeinthefastlane.com]

  Aortic Insufficiency in Aortic Dissection (click to play) 5) Neurological deficits - such as limb weakness/numbness or disturbances in vision, hearing or speech, or altered mental status (e.g. confusion, decreased responsiveness or coma) may be caused [calshipleymd.com]

  Monitoring for limb ischemia via peripheral pulses and cyanosis, limb weakness or paresis, or continued pain is worrisome for a complicated type B dissection requiring surgical intervention. C. [clinicaladvisor.com]

A workup for secondary hypertension was negative and no other risk factors for aortic dissection were determined. [ncbi.nlm.nih.gov]

Workup for aortic dissection in STEMI patients should be reserved for those patients with a significant pretest probability of dissection. [emergencymedicinecases.com]

Diagnostic Workup In the setting of suspected aortic disease, the diagnostic workup may include ECG, chest radiography, myocardial markers, transthoracic echocardiogram, transesophageal echocardiogram, CT, and MRI. [dx.doi.org]

Patients who present to the outpatient setting need to be quickly identified for expeditious transfer for further workup and treatment. Miz and Sam Ashoo discuss both typical and atypical presentations for aortic dissection. [hippoed.com]

• Pericardial Effusion

  Bedside transthoracic echocardiography revealed a pericardial effusion. Cardiac tamponade ensued and the patient passed away shortly after presentation. [ncbi.nlm.nih.gov]

  Her transthoracic echocardiogram showed good left ventricular systolic function, with mild dilatation of the ascending aorta (4.5 cm) ( Figure 1A ), without evidence of pericardial effusion. Figure 1. [dx.doi.org]

  Note that there is no pericardial effusion. IMH thickness stays below 2 cm, making regression of this Type B IMH likely (up to 80%). [radiologyassistant.nl]

• ST Elevation

  We report a case of an ascending aorta IMH in a patient admitted to hospital with epigastric and chest pain with ST-elevation myocardial infarction in inferior leads. [ncbi.nlm.nih.gov]

  […] aortic rupture aortic regurgitation acute myocardial infarction cardiac tamponade end-organ ischaemia (brain, limbs, spine, renal, gut, liver) death INVESTIGATIONS Bedside ECG normal inferior ST elevation (right coronary dissection) but can be any STEMI [lifeinthefastlane.com]

  […] abdominal organ ischemia limb ischemia ischemic or embolic stroke paraplegia: involvement of the artery of Adamkiewicz If the aortic dissection involves the aortic root it may result in involvement of the coronary arteries and can present similarly to ST-elevation [radiopaedia.org]

• Electrical Alternans

  Electrical Alternans in Cardiac Tamponade Laboratory findings Lab findings in aortic dissection are variable and most are very non-specific. [calshipleymd.com]

  alternans (tamponade) Laboratory leukocytosis Cr elevation with renal artery involvement tropnonin elevated if dissection causes myocardial ischaemia D-dimer – if negative dissection is very unlikely, but not sufficient to rule out Cross-match Various [lifeinthefastlane.com]

• Pleural Effusion

  Left pleural effusion is common. [merckmanuals.com]

  IMH thickness > 2 cm - Pericardial effusion (to less extend pleural effusion) IMH may persist or evolve into aneurysm or PAU Associated PAU - worse prognostic outcome On the left a Intramural hematoma, hyperdense on a NECT. Same case. [radiologyassistant.nl]

  Pleural effusions, more commonly in descending aortic dissections, and typically left sided. [en.wikipedia.org]

  effusion (L>R), tracheal shift, left apical cap, deviated NGT. [lifeinthefastlane.com]

Endovascular stenting remains an option for treatment of some type B dissections. [emedicine.medscape.com]

However, the results of this treatment may improve when associated with other imaging tests. [ncbi.nlm.nih.gov]

CT scanning may be used to confirm the diagnosis but is less helpful in complications and prognosis. [patient.info]

The patient obtained favorable clinical prognosis and was smoothly discharged. During subsequent follow-up, he remained physically stable. [ncbi.nlm.nih.gov]

The etiology could not be reversed and the patient died. Critical care ultrasound is an important skill that intensivists should master for fast screening of life-threatening complications in patients with AAAD. [ncbi.nlm.nih.gov]

The etiology may differ depending on the location of the aneurysm. [omicsonline.org]

In young patients, an underlying etiology (i.e. Marfan’s) should be explored. E. Common Pitfalls and Side-Effects of Management. [clinicaladvisor.com]

Type of Dissection, Predisposing Conditions, and Etiology All patients had Stanford type A dissection; DeBakey type I was identified in 60.8% of patients. [dx.doi.org]

[…] new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies (including biomarkers and imaging), endograft design, and surgical treatment, which have led to a better understanding of the epidemiology [ncbi.nlm.nih.gov]

Epidemiology: 10,000 deaths in the US annually Incidence 16/100,000 for men, 9/100,000 for women ( Milewicz 2011 ) Ratio of Aortic Dissection (AD) to Acute Coronary Syndrome is 1:600 22% of cases undiagnosed prior to death (Cline 2012) Predisposing Factors [coreem.net]

Epidemiology and clinicopathology of aortic dissection. Chest. 2000 ; 117 :1271–1278. Crossref Medline Google Scholar 3. Feldman M, Shah M, Elefteriades JA. Medical management of acute type A aortic dissection. [dx.doi.org]

Aortic dissection: epidemiology, pathophysiology, clinical presentation, and medical and surgical management. In: Sidawy AN, Perler BA, eds. Rutherford's Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA: Elsevier; 2019:chap 81. [nlm.nih.gov]

The objective of the present study was to reappraise epidemiology and long-term outcomes in subjects with thoracic aortic disease in a large contemporary population. [web.archive.org]

This comprehensive review discusses the pathophysiology, classification, clinical manifestations, early diagnosis, and management of this important cardiovascular emergency. [ncbi.nlm.nih.gov]

The Stanford classification: Type A: Dissection involving any part of the ascending aorta Type B: Dissection remaining confined to the descending thoracic aorta Pathophysiology When the intima becomes compromised, a tear can occur leading to dissection [healio.com]

Aortic dissection: epidemiology, pathophysiology, clinical presentation, and medical and surgical management. In: Sidawy AN, Perler BA, eds. Rutherford's Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA: Elsevier; 2019:chap 81. [nlm.nih.gov]

Endovascular fenestration on the abdominal aorta is effective for preventing visceral malperfusion in aortic dissection. [ncbi.nlm.nih.gov]

PREVENTION: Medical management is essential to preventing aortic dissection. If you have thoracic aortic disease, medical management that includes optimal blood pressure control, aortic imaging and genetic counseling is strongly recommended. [johnritterfoundation.org]