Aortic dissection

Last reviewed: 7 Jan 2023
Last updated: 20 Sep 2022



History and exam

Key diagnostic factors

  • acute severe chest pain
  • acute severe interscapular and lower back pain
  • features of Marfan syndrome
  • features of Ehlers-Danlos syndrome
  • left/right blood pressure differential
  • pulse deficit
  • diastolic murmur
  • syncope
  • hypotension
More key diagnostic factors

Other diagnostic factors

  • hypertension
  • dyspnea
  • altered mental status
  • paraplegia
  • hemiparesis/paresthesia
  • abdominal pain
  • limb pain/pallor
  • left-sided decreased breath sounds/dullness
Other diagnostic factors

Risk factors

  • hypertension
  • atherosclerotic aneurysmal disease
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • bicuspid aortic valve
  • annuloaortic ectasia
  • coarctation
  • smoking
  • family history of aortic disease or connective-tissue disorder
  • older age
  • giant cell arteritis
  • overlap connective-tissue disorders
  • surgical/catheter manipulation
  • cocaine/amphetamine use
  • heavy lifting
  • pregnancy
  • nondiabetic
More risk factors

Diagnostic investigations

1st investigations to order

  • ECG
  • chest x-ray
  • cardiac enzymes
  • computed tomography angiography
  • renal function tests
  • liver function tests
  • lactate
  • complete blood count
  • type and cross
More 1st investigations to order

Investigations to consider

  • D-dimer
  • transthoracic echocardiography
  • transesophageal echocardiography
  • magnetic resonance angiography
  • intravascular ultrasound
  • smooth muscle myosin heavy chain protein
More investigations to consider

Treatment algorithm


hemodynamically unstable: suspected aortic dissection


confirmed aortic dissection


after hospital discharge



Caitlin W. Hicks, MD, MS

Assistant Professor of Surgery

Division of Vascular Surgery and Endovascular Therapy

The Johns Hopkins University School of Medicine




CWH receives grant funding from NIH/NIDDK, the Society for Vascular Surgery, and the American College of Surgeons; and has been reimbursed by W.L. Gore and Cook Medical for speaker engagements.

James H. Black III, MD, FACS


Vascular Surgery and Endovascular Therapy

Department of Surgery

The Johns Hopkins University School of Medicine




JHB is a proctor for Cook, Inc.


Dr Caitlin W. Hicks and Dr James H. Black III would like to gratefully acknowledge Professor Hazim J. Safi, Dr Jeffrey Wu, and Dr Eric E. Roselli, previous contributors to this topic.


HJS, JW, and EER declare that they have no competing interests.

Peer reviewers

Evan Lipsitz, MD

Associate Professor of Surgery

Acting Chief

Division of Vascular and Endovascular Surgery

Montefiore Medical Center and the Albert Einstein College of Medicine




EL declares that he has no competing interests.

  • Aortic dissection images
  • Differentials

    • Acute coronary syndrome
    • Pericarditis
    • Aortic aneurysm
    More Differentials
  • Guidelines

    • Clinical practice guidelines on the management of Type B aortic dissection
    • Clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms
    More Guidelines
  • Patient leaflets

    Aortic dissection

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer