Acute Aortic Disease.. - Index of

Putting It All Together: Symptoms, Signs, and Images 71
Table 3 Atypical Symptoms inAcute Aortic Conditions in Different Patients
Patients at risk for presenting with Atypical symptoms of acute
atypical symptoms aortic conditions
Elderly (age >70) Painless acute aortic condition
Female Abdominal pain
Diabetic Syncope
Existing aortic aneurysm Altered mental status
Prior cardiovascular surgery Stuttering, recurrent pain
with atypical presentations will often present later in the natural course of dissection
and are at high risk for hemodynamic derangement, malperfusion, and death
if the diagnosis is missed or further delayed (2,23).
Therefore, it is imperative for the clinician to recognize patients who
are more likely to present atypically and aggressively pursue the diagnosis of an
acute aortic condition in any patient who presents with unexplained hypoperfusion
to an end organ or extremity. Symptoms consistent with end-organ malperfusion
may include abdominal pain, neurological deficit due to ischemia of the
spinal cord, limb ischemia, and renal failure. The specific symptom complex
may help localize the anatomic extent of the dissection along the aorta and its
major branches.
In IRAD, up to 6.4% of patients denied any pain on presentation, consistent
with the 5% to 15% incidence, reported in the literature. When compared to
patients who describe pain on presentation, these patients are significantly more
likely to have syncope, congestive heart failure, stroke, and in-hospital death.
Alarmingly, patients presenting without pain had a median time of 29 hours
for diagnosis versus 10 hours in those who presented with typical pain. Painless
aortic dissection is more common in the elderly patients with existing aortic
aneurysms, prior cardiovascular surgery, and diabetics (8,10,12,26). Women
are more likely than men to have painless aortic dissection (10). Mechanisms of
painless aortic dissection are poorly understood, but may be related to conditions
in which the aorta dissects gradually or in some manner spares the richly
innervated adventitia. Prior cardiovascular surgery and surgical aortic manipulation
may also alter the patient’s perception of aortic pain, and diabetics
may be vulnerable to painless dissection due to denervation of perioaortic pain
receptors (12,26,27).
Another atypical presentation is that of acute aortic dissection manifesting
in a patient who presents with a primary or isolated complaint of abdominal
pain. This challenging presentation was reported in approximately 5% of patients
in IRAD, and each patient was ultimately diagnosed with acute Type B aortic
dissection. Although relatively rare, patients presenting in this manner had significantly
higher rates of in-hospital death when compared to patients with more
typical symptoms.