Aortic dissection history and symptoms

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]

Overview

67% of patients with aortic dissection present with acute symptoms (<2 weeks), and 33% with chronic symptoms (>= 2 weeks). 74% of patients who survive the initial tear typically present with the sudden onset of severe tearing pain.

History

The presence of syndromes/ diseases or procedures that place the patient at high risk of dissection should be ascertained:

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

Common Symptoms

Chest Pain

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

Neck, throat, jaw, and unilateral face pain are also seen more commonly in those with type I or type II dissection.

Back Pain

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

Pleuritic pain suggests acute pericarditis associated with hemorrhage into the pericardial sac.

Painless Dissection

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).

Less Common Symptoms

• Abdominal pain due to mesenteric ischemia
• Cardiac arrest occurs in 4% of patients
• Claudication due to iliac artery occlusion
• 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 may occur and in 50% of cases, the etiology of the syncope is hemorrhage into the pericardial sac causing pericardial tamponade
• Upper gastrointestinal (UGI) bleed
• Vocal cord paralysis and hoarseness (compression of the recurrent laryngeal nerve)

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)

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

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. (Level of Evidence: C)"