Aortic Dissection

Aortic dissection (“AD”) is a medical condition that can be missed by emergency medicine doctors with potentially deadly consequences. John Ritter, the famous actor, died as a result of previously undiagnosed AD.

If you or a loved one has suffered as a result of undiagnosed and untreated AD, please contact the law office of James R. Page for a free consultation. Mr. Page is knowledgeable and experienced in the evaluation of such matters.

Aortic dissection (“AD”) is a lethal medical condition that, if untreated, will surely lead to death. Survival is significantly improved by timely diagnosis and institution of appropriate surgical and/or medical therapy.

Aortic dissection is believed to begin with the formation of a tear in the aortic intima that directly exposes an underlying diseased medical layer to the driving force of intraluminal blood, thereby dissecting the aortic wall. This results in a blood filled space, or false lumen, that develops in the aortic media. This false lumen can propagate or result in a temporary “spontaneous cure”. Once rupture occurs, however, death is almost immediate.

There are two dominant medical tests for emergency medicine: Rosen’s and Tintinalli’s. Each of these texts covers AD. As described in each, there is a “classic” description of the clinical presentation of AD. A patient who reports acute onset of severe chest pain, (often described as “sharp”) which is most severe at onset and which radiates from the chest to the back, is “classic”. This pain may also radiate above and/or below the diaphragm. The onset of AD is often accompanied by symptoms of diaphoresis (sweating), nausea, vomiting, lightheadedness, or severe apprehension.

The following statements come from a Jan. 2000 article in American Journal of Emergency Medicine, entitled “Diagnosis of Acute Thoracic Aortic Dissection in the Emergency Department”:

The pain is invariably described as sudden or abrupt in onset and severe in nature. The quality of pain described by patients in this study was most commonly “sharp”, “pressure”, “pleuritic”, or “burning”; no chart in this study documented a “tearing” or “ripping” quality of pain. Pain which is sudden, severe, maximal as its onset, and migratory over time is a hallmark of AD. One prior inpatient study reported that 71% of patients experienced migratory pain during their hospitalization. In the current study, migratory pain was present in approximately one-quarter of patients during their ED course.

. . .

The location of pain was most predictive of a suspected diagnosis of acute AD by an emergency physician. A patient presenting with chest and back pain was suspected of having aortic dissection 86% of the time; however, only 39% of the patients in this study presented with the “textbook” description of AD. Prior studies have also shown that concomitant chest and back pain comprise a minority of AD presentations with reported incidences of 26% to 41%.

. . .

In summary, emergency physicians commonly suspected the diagnosis of AD in patients presenting with concomitant chest and back pain. This presentation, although classically described, occurred in a minority of patients. Epigastric or abdominal pain represented a third of all painful presentations; however, emergency physicians rarely suspected AD in this clinical setting. A history of sudden cataclysmic pain should raise suspicion for the diagnosis. Absence of suggestive physical or chest radiograph findings should not deter further imaging studies. A high level of suspicion for this disease and its protean presentations is crucial to early diagnosis and prevention of morbidity and mortality.

There are many risk factors for AD. However, it is well-recognized that AD can occur even in the absence of a recognized risk factor. The various risk factors associated with AD include:

1. Hypertension
2. Family History of AD
3. Connective Tissue Disorders that include Marfan’s and Ehlers-Danlos Syndrome
4. Trauma
5. Morbid Obesity
6. Pregnancy
7. Obstructive Sleep Apnea
8. Congenital Heart Disease
9. Bicuspid aortic valve
10. Aortic coartation
11. Illegal Drug Use (Cocaine or Meth)
12. Aortic Stenosis
13. Adult Polycystic Kidney Disease
14. Turner and Noonan Syndromes
15. Metabolic Disorders such as homocystinuria, familial hypercholesterolemia
16. Osteogenesis Imperfecta
17. Annuloaortic Ectasia

Although AD is commonly seen in older people, it may present in patients from
childhood through old age.