On the Shoulders of Giants
Sudden-onset, severe ("worst-ever"), sharp chest pain was the hallmark of type A and B aortic dissection. Ripping or tearing pain was present in only half of patients. Classic features of aortic regurgitation murmur and pulse deficit were frequently lacking.
Why does this matter?
Aortic dissection is a life threatening disease entity. We are all taught the classic clinical features, such as ripping or tearing pain with radiation to the back, but often these are lacking. Knowing when to suspect and workup this illness may save a life. Rapid treatment to control blood pressure and obtain definitive surgery offers the best chance of survival.
Sudden, severe, "worst ever" chest pain is bad
This was a large registry of type A and B aortic dissection from 1996 -1998. They found that in 464 patients, the most common presentation was sudden onset, severe ("worst-ever"), sharp chest pain. Mean age was 63. Type A was more common than type B, 62% of cases. Tearing or ripping pain was present in only half of type A and B dissections. Pain in the back was present in over half. Other classic clinical features like aortic regurgitation occurred in only 31%; left to right pulse deficit in only 15%. ECG was normal in 30%, with non-specific changes in another 40%. CXR was normal in up to 16%. The best diagnostic test was (and still is) CT. Mortality at 30 days was high, 35% for type A; 15% of type B.
The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000 Feb 16;283(7):897-903.