Atypical Presentations of Emergency Room Patients With Acute Aortic Dissection

A Retrospective Cohort Study

Patients with acute aortic dissection are subject to substantial morbidity and mortality. Without treatment the death rate after symptom onset rises by 1–2% per hour, whereas if a diagnosis is made rapidly and adequate treatment given, a 30-day survival rate of more than 90% can be achieved (1, 2). Acute onset of tearing or stabbing pain in the chest, back, or abdomen is typical (1, 2, 3). In spite of this the suspected diagnosis is initially made only in 15–43% of ultimately confirmed cases, and up to 30–50% remain undetected before death (4). Atypical presentations increase the probability of a delayed diagnosis and are associated with greater morbidity and mortality (5). If an acute aortic dissection is clinically suspected, risk stratification by using the Aortic Dissection Detection Risk Score (ADD-RS) is indicated, possibly complemented by a D-dimer test and followed by immediate computed tomography (CT) angiography (CTA). Therapeutically, the main attention is initially on blood pressure and frequency control. Type A dissections require emergency related surgical care, whereas Type B dissections are treated primarily conservatively and in case of complications require intervention (2, 3).

Methods

We carried out a retrospective analysis of consecutive patients with acute aortic dissection (Type A, B, and non-A/non-B) who were treated in the emergency center at Luzerner Kantonsspital, Lucerne, one of Switzerland’s largest hospitals. About a third of cases (32.9%) came from nationwide referrals. Cases were followed up until April 2025. Deaths were recorded in Switzerland’s national death register. We used SPSS version 30 (IBM) for our statistical analyses, using logistic regression and Cox regression analyses.

The primary endpoint was the rate of atypical initial symptoms in patients with a diagnosis of aortic dissection. We tested the hypothesis that the rate of atypical initial symptoms corresponds to the reference values described in the literature. Furthermore we recorded overall mortality (survival to death or censoring on 26 April 2025) and differences between typical and atypical initial symptoms. The classification into typical and atypical followed the current professional recommendations (2). We defined as typical a combination of one characteristic (sudden, strong, tearing, stabbing, wandering) and chest, abdominal, or back pain. All other cases were classified as atypical.

Results

We included 137 patients in our analysis (59.9% male, mean age 68 ±12.1 years). 73% of patients had Stanford Type A aortic dissection , and more than half (51.8%) had atypical initial symptoms. Altogether, 48.2% had typical pain, 29.9% had atypical pain, and 21.9% had no pain; 20.4% displayed neurological deficits, 15.3% impaired vigilance, 24.1% syncope or dizziness; 12.4% had symptoms of extremity ischemia, 15.3% had dyspnea, and 16.8% had other symptoms. 65% of patients were admitted by the ambulance service. 5.8% of patients were resuscitated. The overall mortality in the cohort was 35.8%. The most common cardiological risk factor was arterial hypertension in 65% of patients (Table).

Table

Baseline characteristics of patients with a main diagnosis of aortic dissection

Men had a lower probability than women for atypical symptoms (odds ratio [OR] 0.45, 95% confidence interval [CI]: [0.22; 0.90]; p=0.025). The probability was notably higher for a Type A dissection of being associated with atypical symptoms (OR 4.22 [1.84; 9.68]; p<0.001). Age and the presence of cardiovascular risk factors were not relevantly associated with atypical initial symptoms. An increased mortality risk was associated with age (hazard ratio [HR] 1.06 [1.03; 1.09]; p<0.001), female sex (HR 2.39 [1.36; 4.22]; p=0.003), the symptoms “no pain” (HR 2.61 [1.45; 4.69]; p=0.001) and “impaired vigilance” (HR2.00 [1.02; 3.92], p=0.045), the vital parameters blood pressure, respiratory rate, and oxygen saturation, the laboratory parameters hemoglobin, estimated glomerular filtration rate (eGFR), lactate, and troponin T (hs-TnT), and being presented to the hospital by the ambulance service. The presence of atypical initial symptoms was not associated with overall mortality.

Discussion

In the literature (1, 2, 3), typical initial symptoms were described in 62–85% of patients with acute aortic dissection. In our cohort at a central hospital, 51.8% of patients presented with atypical initial symptoms. One possible explanatory approach for the raised rate of atypical presentations might be the higher proportion of female patients (40% versus 30–36% in international registers), since in our analysis women presented more commonly with atypical symptoms. Furthermore, the increasing availability of CT may contribute to the more common detection of aortic dissections in a setting of atypical symptoms, which is consistent with our observation that they had often been diagnosed as an incidental finding. The higher rate of Type A dissections (73% versus 62–68% in the literature) and the patients’ older age (68 years versus 61–63 years) in our cohort might also explain the increase in atypical initial symptoms, since both factors have been associated with atypical presentations in the literature. Surprisingly, the presence of atypical initial symptoms does not have any effect on the overall mortality. The association of female sex with increased mortality can possibly be explained with patients’ older age (65.9±12.5 years versus 71.3±10.8 years; p=0.01).

The study’s limitations include the retrospective single-center design. Because of the nationwide catchment area and in view of the low incidence in the comparatively large cohort the results can be considered representative. The retrospective addition of data from the medical history may have led to hindsight bias (a tendency to assess a known result as predictable with hindsight). Furthermore, patients who died before reaching hospital and non-identified cases post mortem may have led to selection bias.

Prospective multicenter studies, ideally including international cohorts, are needed to analyze the diagnostic challenges of acute aortic dissection, optimize the identification of atypical presentations, and ensure the generalizability of the results to different healthcare systems.

Rahel Diethelm, Gregor Blank, Luca Schuler, Michael Christ, Stefan Venturini
Notfallzentrum, Luzerner Kantonsspital
(Diethelm, Schuler, Christ, Venturini) [e-mail]
Medizinische Klinik, Zuger Kantonsspital (Blank)

Acknowledgment
This retrospective cohort study was created in the context of a doctoral dissertation at the University of Lucerne, Switzerland.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 31 October 2025, revised version accepted on 13 March 2026.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as: Diethelm R, Blank G, Schuler L, Christ M, Venturini S: Atypical presentations of emergency room patients with acute aortic dissection: A retrospective cohort study. Dtsch Arztebl Int 2026; 123: 310–11. DOI: 10.3238/arztebl.m2026.0047

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