Aortic dissection

Aortic dissection is the most common acute aortic syndrome, and it is an important differential diagnosis of chest pain. It is three times more common than an abdominal aortic aneurysm rupture and is associated with a high mortality.

Aortic dissection occurs when blood enters the medial layer of the aortic wall, creating a false lumen. Other acute aortic syndromes include intramural hematoma, periaortic haematoma and penetrating atherosclerotic ulcer.

The following history, examination findings and risk factors are taken from the MDCalc aortic dissection detection risk score.

History

Sudden onset of severe chest, abdominal or back pain described as abrupt in onset, severe in intensity and of a ripping, tearing, sharp or stabbing quality.

Other symptoms are related to progression of the dissection and compromised end-organ perfusion.

Can present as acute coronary syndrome. Consider aortic dissection prior to administering antiplatelet or fibrinolytic agents.

Examination

• Pulse deficit
• Systolic BP differential
• Focal neurological deficit (in conjunction with pain)
• Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)
• Hypotension, syncope or shock state

Immediate risks to the patient

• Haemodynamic collapse (aortic rupture)
• Aortic regurgitation
• Acute myocardial infarction
• Tamponade
• Haemothorax
• End organ ischaemia (further progression of dissection)
• Altered consciousness or neurologic compromise (carotid involvement)
• Associated complications of branch vessel involvement (renal, mesentery)

Risk factors

• Hypertension
• Atherosclerotic aneurysmal disease
• Cocaine use
• Connective tissue disease, such as Marfan syndrome
• Family history of aortic disease
• Recent aortic manipulation and/or cardiac surgery
• Known thoracic aortic aneurysm
• Known aortic valve disease
• Male (more common in men)

Investigations

Ensure early diagnosis so appropriate treatment can be started as soon as possible.

• ECG – rule out acute coronary syndrome:
  • ST segment depression may occur with acute dissection
  • ST elevation occurs rarely
  • troponin: high sensitivity
  • myocardial ischaemia or infarction may be present in 10% to 15% of patients with aortic dissection.
• Renal and hepatic function: if perfusion is compromised there will be evidence of compromised renal or hepatic function.
• Full blood count, group and hold and/or cross match. May need blood if urgent surgery required
• D-dimer may be useful to rule out aortic dissection in low-risk patients.

Imaging

• CT angiogram is preferred for haemodynamically stable patients
• Transthoracic echocardiogram or transoesophageal echocardiogram for unstable patients
• CXR – look for:
  • mediastinal widening or pleural effusion
  • abnormal aortic contour >0.5 cm from edge of calcification to edge of contour

Management

• Advanced life support if required
• Urgent referral to cardiothoracic, intensive care if strong suspicion
• Advanced haemodynamic support as appropriate (fluid resuscitation, consider activating massive transfusion protocol, invasive haemodynamic monitoring, manage hypertension or hypotension)
• Target HR 60-80
• Target right arm BP 100-120 systolic: right arm likely most accurate or use higher number.
• Stanford type A: surgical repair represents the mainstay of treatment.
• Stanford type B: medical management is the gold standard although endovascular surgery sealing of the intimal entry tear offers potential management in the complicated tears.

Resources

• Overview of acute aortic dissection and other acute aortic syndromes
  Source: UpToDate
• Aortic dissection - Symptoms, diagnosis and treatment
  Source: BMJ Best Practice
• Asha SE, Miers JW. A systematic review and meta-analysis of D-dimer as a rule out test for suspected acute aortic dissection. Ann Emerg Med. October 2015 66;4;368-377. DOI: 10.1016/j.annemergmed.2015.02.013.
• Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: The ADvISED prospective multicenter study. Circulation. 2018 16 Jan;137(3):250-258. DOI: 10.1161/CIRCULATIONAHA.117.029457
• Aortic dissection detection risk score
  Source: MDCalc

Change log

Date	Section updated	Change
May 2025	All	Review for currency and accuracy. Minor revisions and restructure of text.  Removal of medications. Updated links in resources section.