Presentation of Acute Aortic Syndromes

The majority of patients with an acute aortic syndrome have a history of hypertension. The most common presenting symptom of acute aortic syndromes is pain, regardless of whether the eventual diagnosis is aortic dissection, intramural hematoma, or symptomatic penetrating aortic ulcer. It is usually described as severe or as the worst pain ever experienced, with a sudden onset, and can be reported in the chest, back, or abdomen. Other presenting signs and symptoms depend on the extent of the lesion. Syncope can be caused by associated cardiac tamponade or extension of the dissection into the brachiocephalic vessels, which can also lead to stroke. Obstruction of branch vessels by the dissection flap can lead to weak or absent peripheral pulses with presence of visceral, renal, and/or limb ischemia. Extension of the dissection to the spinal cord blood supply can cause acute paraplegia. On physical examination, the patient may give a restless, agitated or apprehensive impression, and appear shocked, cold, and clammy. Tachycardia is almost always noted, but while hypertension is one of the most important risk factors, it is not always present on initial examination of an acute aortic syndrome. On auscultation, a new onset diastolic decrescendo murmur points to the presence of aortic valve insufficiency. Auscultation might also reveal a pericardial rub or distant heart sounds, indicative of cardiac tamponade. The electrocardiogram and laboratory tests are generally normal or show nonspecific changes.