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Aortic Dissection

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Type A vs B, symptoms, imaging, BP/HR targets, medication strategy, surgical/vascular escalation.

Covers Stanford type A and type B dissection.

Last reviewed

June 12, 2026

Disclaimer: Educational reference only. Not a substitute for clinician judgment, local protocols, or current guideline review.

Clinically reviewed by the site owner. Still verify against the sources above and local protocol before clinical use.

Intimal tear → blood enters the aortic wall, creating a false lumen. A time-critical emergency.
Stanford type A: involves the ascending aorta → surgical emergency (untreated mortality ~1–2% per hour early).
Stanford type B: begins distal to the left subclavian → usually medical management unless complicated.

Sudden, severe, tearing/ripping chest or interscapular back pain, maximal at onset, may migrate.
Pulse deficit or >20 mmHg systolic BP differential between arms.
New aortic regurgitation murmur, syncope, or signs of malperfusion (stroke, limb/visceral/renal ischemia).
Either hypertension (common) or hypotension/shock (ominous — rupture or tamponade).
Risk: long-standing HTN, Marfan/Loeys-Dietz, bicuspid aortic valve, prior aortic disease, cocaine, pregnancy.

CT angiography of chest/abdomen/pelvis — first-line and the diagnostic workhorse in the stable patient.
TTE is a fast bedside adjunct — it can reveal tamponade, AR, a proximal flap, or root dilation, but a normal TTE does NOT exclude dissection.
TEE is the definitive bedside study when the patient is too unstable to travel for CT (also used intra-operatively); MRA is an option if stable with contrast/radiation concerns.
ECG (exclude STEMI; an aortic flap involving the RCA can mimic an inferior MI).
CXR may show a widened mediastinum (not sensitive enough to exclude).
Type & screen, CBC, renal function, lactate. A D-dimer has a high negative predictive value but is not a stand-alone rule-out.

Target HR <60 and SBP ~100–120 mmHg (lowest tolerated maintaining perfusion).
IV beta-blocker first (e.g., esmolol or labetalol) BEFORE any vasodilator to avoid reflex tachycardia.
Add a vasodilator (e.g., nicardipine or nitroprusside) only after rate control if BP remains high.
Adequate analgesia (pain drives catecholamines and BP).

Type A → emergent cardiothoracic surgery.
Type B → medical therapy unless complicated (malperfusion, rupture/impending rupture, refractory pain or HTN) → TEVAR / vascular surgery.

Do NOT

Give thrombolytics or anticoagulation. If a "STEMI" has an inter-arm BP differential or tearing pain, exclude dissection before lysis.

Hypotension or shock (suspect rupture or tamponade), new neurologic deficit, limb/visceral ischemia, or syncope.
Widened mediastinum with tearing pain → activate surgery/vascular emergently and transfer to a center that can operate.

Maintain strict BP and HR control and lifelong imaging surveillance in known or repaired aortic disease.
Screen first-degree relatives and patients with heritable thoracic aortic disease (Marfan, Loeys-Dietz, familial TAA, bicuspid valve).

Intimal flap on CT angiography (Radiopaedia) — true and false lumens separated by an intimal flap — the diagnostic CTA finding
Widened mediastinum on CXR (WikEM) — classic plain-film clue — suggestive but NOT sensitive enough to exclude dissection

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