AHA/ACC Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (2010)

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Commentary by Reed E. Pyeritz, MD, PhD

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Signs & symptoms


The patient with an aortic dissection usually complains of severe pain, most often in the chest (front, back or both), and commonly between the shoulder blades. Occasionally, the pain may be reported as being in the upper abdomen (if the tear begins in that part of the aorta).

The patient may describe the pain as ripping, tearing, or sharp. It may also be described as pleuritic.

Dissections can cause a variety of other symptoms in the extremities, known as “the 5 Ps”: pain, pallor, pulselessness, paresthesia, paralysis.

The Five Ps:

  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Paralysis

Symptoms and signs of shock are ominous findings, and indicate that the dissection has progressed to the point at which tissue perfusion is compromised.

Classic features of Marfan syndrome and certain other connective tissue disorders may also suggest aortic dissection, such as:

  • Disproportionately long arms, legs, fingers, and toes
  • Pigeon breast (in which the breast bone protrudes forward)
  • Funnel chest (in which the breast bone caves inward)
  • Marked curvature of the spine

Rarely, if the dissection compromises blood flow to the spinal cord, there may be weakness in one or both legs or arms. In addition, neurologic events that would seem to be due to a stroke or transient ischemic attack may be due to a dissection.

IMPORTANT:Take note if the patient tells you he/she has had an aneurysm, Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, a mutation in a gene which predisposes to familial thoracic aortic aneurysms/dissections, or a family history of thoracic aortic aneurysms/dissections This should alert the EMS provider to consider rapid transport with treatment provided en route.