Clinical findings

The patient is usually in severe pain and may appear shocked, but there may be no other obvious physical abnormality. Shock may be a consequence of hypovolemia, cardiac tamponade, or aortic regurgitation. Apparent 'shock', in which the patient is cold and clammy but has a normal or raised blood pressure, is described frequently. Absent or unequal pulses are said to be characteristic of the condition but are only found in a minority; approximately 25 per cent will have reduced pulses in one or both arms, and a similar percentage will have abnormal leg pulses. The right arm and the left leg are involved more commonly. Aortic regurgitation develops in over 50 per cent of patients with dissections of the ascending aorta but is initially severe only in a minority. Involvement of other major vessels may produce symptoms or signs suggestive of ischemia in the relevant arterial territory. Other findings may be of pleural or pericardial fluid due to leakage of blood, sometimes with cardiac tamponade. This may develop suddenly and catastrophically but, more commonly, is of gradual onset. Aortic rupture in type A dissections is almost invariably preceded by the development of a pericardial effusion. Patients presenting late frequently have a fever due to large quantities of extravasated blood; if there is associated aortic regurgitation, it is possible to make a mistaken diagnosis of endocarditis.

Dissection should be considered in the differential diagnosis of any patient with severe chest or upper abdominal pain. It is particularly important to consider the diagnosis in the initial assessment of patients with apparent myocardial infarction before giving thrombolytics. Important differential diagnoses include ischemic cardiac pain, pancreatitis, esophageal pain, and massive pulmonary embolus.

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