Key messages

• Consider dissection in the differential diagnosis of all acute chest pain.

• Unequal pulses are only present in a minority of cases.

• CT scanning is the most convenient initial investigation.

• Transesophageal echocardiography is useful for refining the diagnosis of acute ascending aortic dissection. This can be performed at the bedside or in the operating room.

• Magnetic resonance imaging is the investigation of choice in descending aortic dissection. Presentation and diagnosis

The clinical features are composed of pain due to the dissection itself, symptoms and signs of ischemia or infarction in arterial territories involved in the dissection, aortic valve involvement, and leak of extravasated blood into other structures, typically the pleura or pericardium, producing effusions and tamponade. The features are highly variable and may mimic a number of other conditions.

Although painless dissections do occur, dissection characteristically produces a severe tearing chest pain of abrupt onset which reaches an immediate crescendo and may be very poorly localized. The initial pain may mimic myocardial infarction but frequently extends beyond the usual boundaries of cardiac pain, often penetrating through to the back or radiating into the abdomen, particularly as the dissection progresses. Typically, dissections involving the ascending aorta produce anterior chest pain, while interscapular pain usually implies involvement of the descending aorta. Patients can frequently pinpoint the exact moment that it developed and sometimes relate it to a sudden movement or physical strain. Extension of the dissection may lead to remote ischemic pain or loss of function which may dominate the clinical picture. Severe aortic regurgitation may cause acute left ventricular failure. Patients may also present with collapse, loss of consciousness, or stroke if the dissection involves the innominate or left common carotid arteries. Similarly, separation of intercostal arteries from the aortic lumen may lead to paraplegia. Dissection of either coronary artery may cause sudden death.

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