Clinical characteristics of patients diagnosed with aortic dissection in the emergency department: a case series

Abstract

Objectives: Aortic dissection (AD) is an emergency condition with high mortality rates. Classically, patients present with sudden onset of severe, ripping or tearing pain in the chest and back, although `atypical` presentations also exist. The objective of this study is to evaluate characteristics of the history and physicalexamination of patients diagnosed with aortic dissection in the emergency department (ED) and to highlight differences from signs and symptoms defined as `classical`.
Materials and Methods: Computer records were quried for patients admitted to the ED and eventually diagnosed with AD in a fifty-four month period. Demographic variables, chief complaints, pain characteristics, risk factors for AD, vital signs, findings on examination, laboratory results including ECG, cardiac markers, chest X-ray, and computed tomography (CT) were obtained retrospectively from ED charts and recorded on data sheets. Stanford classification of the AD and how the diagnosis was established were also noted.
Results: Forty seven cases (32 males (68,1%); 15 females (31.9%) mean age 66; range 25 to 87 years) were identified. Pain was described by 38 patients (80.9%). The most common presenting complaints were back pain (40,7%, n=19), chest pain (36,2%, n=17), abdominal pain (25,5%, n=12), syncope (19,1%, n=9), and shortness of breath (17%, n=8). Pulse deficit was recorded in 12 (25,5%), discrepancy in blood pressure readings between left and right arms in eight (17%, n=8), cardiac murmur in 40,4% (n=19), altered mental status in 14,9% (n=7) and neurologic deficit in 12,8% (n=6) patients. Tearing chest pain was recorded in only 8 patients (21,1%). Contrast-enhanced CT was the diagnostic modality in 42 (89,4%) cases and 31 patients (65%) had a widened mediastinnum recorded in ED the interpretation of the chest X-ray. Thirty-two (68,1%) patients were diagnosed to have AD with Stanford A classification, while the remaining 15 (31,9%) had Stanford B AD.
Conclusion: Symptoms and signs of AD in the ED may be substantially different from what is `classically` expected. Only a minority of the patients reported sudden onset tearing pain in their chest and back. Pulse deficit, carotid or abdominal bruits, cardiac murmurs, blood pressure discrepancies are valuable albeit uncommon findings on examination. Further studies are required to define population-based clinical presentation of AD.