Acute Aortic Disease.. - Index of

Putting It All Together: Symptoms, Signs, and Images 69
Table 1 Predisposing Factors for Acute
Aortic Conditions
Hypertension
Advanced age
Atherosclerosis
Smoking
Cocaine or amphetamine use
Male gender
Connective tissue disorders
Marfan’s syndrome
Ehler’s Danlos syndrome
Aortic coarctation
Bicuspid aortic valve
Vascular inflammation
Giant cell arteritis
Takayasu arteritis
Syphilis
Iatrogeni
Catheter instrumentation of aorta
Prior or recent cardiac surgery
Aortic cross clamping/aortotomy
SYMPTOMS
Typical Symptoms
Because dissection may present with a broad range of symptoms, it is essential for
the clinician to maintain a high index of suspicion for acute aortic syndrome when
evaluating any patient who carries the usual predisposing risk factors (Table 1).
From our experience with IRAD, the single most reliable presenting symptom in
patients with acute dissection is the sudden onset of severe pain localized to the
anterior chest or back, and less often, the abdomen. Contrary to classic teaching,
patients are more likely to describe the quality of pain as sharp, as opposed to
tearing or ripping. Moreover, the abrupt onset of pain seems to be the most
frequent and consistent characteristic, as it is reported in 85% of both Type A and
Type B aortic dissections (1). The sudden onset of severe pain is typically dramatic
enough that patients often describe the details of the inciting event with a pinpoint
or “freeze-frame” accuracy (13). A pattern of recurrent or stuttering pain should
alert the clinician to the potential progression of an unstable aortic lesion such as
penetrating aortic ulcer or intramural hematoma into overt dissection (Fig. 1)
(4,14–21). The location of pain may sometimes be helpful in distinguishing Type
A from Type B aortic dissection, but this type of assessment should be regarded as
nonspecific. In general, pain localized to the back or abdomen is more consistent
with Type B dissection, whereas patients with Type A dissection usually localize
pain to the anterior chest (Table 2) (1,22,23).