Clinical Features and Differential Diagnosis of Aortic Dissection: Experience With 236 Cases (1980 Through 1990)

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Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.

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MATERIAL AND METHODS

We reviewed the medical records of 235 patients (158 men and 77 women) who had 236 aortic dissections between January 1980 and December 1990. Aortic dissection was confirmed by surgical intervention in 162 patients, autopsy examination only in 27, or computed tomography, transthoracic echocardiography, transesophageal echocardiography, magnetic resonance imaging, or angiography (or some combination of these studies) without surgical confirmation in 47. In one patient with type III aortic

Classification of Patients.

The sex and age distributions and the duration of dissection in our group of patients are summarized in Table 1. Men were affected more commonly than women by a ratio of approximately 2:1 for all types of aortic dissection. The peak incidence was in the sixth and seventh decades of life, but the mean age of patients with type I dissection was approximately 6 years less than that of patients with type II or type III aortic dissection.

The aortic dissection was acute in 158 patients (67%) and

DISCUSSION

The incidence of acute aortic dissection, the most common fatal condition that involves the aorta, may be increasing in the industrialized world.10 If this condition is unrecognized and untreated, the related mortality is high during the first 48 hours.1, 2, 3, 4, 5 Despite major advances in medical and surgical therapy and in rapid and accurate noninvasive diagnostic techniques, a high index of clinical suspicion by the attending physician that leads to early definitive diagnosis is

CONCLUSION

Because of the diverse manifestations of acute aortic dissection and the fatal outcome if it is untreated, the attending physician must have a high index of clinical suspicion for this condition. In a patient, particularly one who has hypertension, with a catastrophic illness, an aortic murmur, and unexplained physical findings of vascular origin, aortic dissection should always be included in the differential diagnosis, and an effective screening test should promptly be performed. As was

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