Aortic Dissection in the ED: Rule It Out, Then Slow It Down

A 58-year-old long-haul trucker walks in at 0300. The pain hit while he was cinching a load strap, it was worst at the start, and it has moved from his chest to between his shoulder blades. His right-arm pressure is 186/102, his left is 148/88, and his heart rate is 104. The ECG shows left ventricular hypertrophy with 1 mm of lateral ST depression, and the triage nurse is holding a chewable aspirin.

Bottom line: abrupt severe pain plus an arm-to-arm pressure gap scores 2 on the aortic dissection detection risk score, so he goes to CT angiography without a D-dimer. With dissection this strongly suspected, it is reasonable to hold the aspirin until the scan; a patient who arrives by EMS may already have had it. If the scan shows a dissection, the beta blocker goes in before any vasodilator, the 2022 ACC/AHA targets are a heart rate of 60 to 80 and a systolic pressure below 120, and a type A dissection gets the cardiac surgeon on the phone now.

Why Aortic Dissection Gets Missed

In eight Swedish emergency departments (630,275 visits, 2017 to 2018), 16 of 98 acute aortic syndromes (16%) were missed at the first visit [1]. Acute coronary syndrome was the working diagnosis in 7 of the 16, missed cases more often had ST elevation or depression, and the median time to diagnosis was 19 hours against 2 hours [1]. Mortality at 90 days was 38% in missed cases and 18% in the rest, a difference that did not reach significance [1].

The wrong pathway costs more than time. In a Toronto referral center (66 patients, 2000 to 2004), 39% of acute aortic syndromes were first misdiagnosed, most often as acute coronary syndrome [2]. All 26 misdiagnosed patients got aspirin, 85% got heparin, and 12% got a fibrinolytic. Antithrombotic exposure was associated with more major bleeding (38% against 13%) and a trend toward higher in-hospital mortality (27% against 13%) [2]. It is a small, old, single-center series, so read the numbers as a warning.

The 2022 ACC/AHA aortic disease guideline puts untreated mortality as high as 1% to 2% per hour [3]. It also corrects the textbook: patients more often describe abrupt, severe, sharp or stabbing pain that is worst at onset than a "tearing" pain, and the guideline tells you to measure the pressure in both arms and both legs [3].

The ADD-RS and D-Dimer Rule-Out

The aortic dissection detection risk score (ADD-RS) gives one point for each category present, for a total of 0 to 3 [4]. The categories are high-risk conditions (Marfan syndrome or other connective tissue disease, a family history of aortic disease, known aortic valve disease, recent aortic manipulation, or a known thoracic aortic aneurysm); high-risk pain (chest, back, or abdominal pain that is abrupt in onset, severe, or ripping or tearing); and high-risk examination findings (a pulse deficit or systolic pressure difference, a focal neurologic deficit with pain, a new aortic regurgitation murmur with pain, or hypotension or shock) [4]. In the International Registry of Acute Aortic Dissection, 95.7% of 2,538 confirmed dissections had at least one marker, and 4.3% scored 0 [4].

The ADvISED study tested the score with D-dimer prospectively in 1,850 patients at six hospitals in Italy, Switzerland, Brazil, and Germany, 13% of whom had an acute aortic syndrome [5]. A D-dimer of 500 ng/mL or more had a sensitivity of 96.7% and a specificity of 64% [5]. Among 924 patients with an ADD-RS of 0 or 1 and a negative D-dimer, 3 had an aortic syndrome, a failure rate of 0.3% (95% CI 0.1% to 1%), and that strategy ruled out half the cohort [5]. A 2024 meta-analysis put the trade-off for different score and D-dimer combinations at 93.1% to 99.8% sensitivity and 21.8% to 67.1% specificity [6]. A retrospective 2026 New Zealand validation in patients who had CT angiography found 1 intramural hematoma, and no type A dissection, among 180 patients with a low score and a negative D-dimer, a failure rate of 0.6% [7].

Two limits apply. An ADD-RS above 1 goes straight to imaging, with no role for a D-dimer. And the rule performs only as well as the history behind it. Scored retrospectively from Swedish charts, with a different D-dimer assay, the same strategy would have recommended CT in 55 of 59 patients with an aortic syndrome and missed 4 [1]. The ACC/AHA guideline describes the combination as a possibly useful strategy in its synopsis and does not make it a numbered recommendation [3]. The logic matches the pretest probability approach to pulmonary embolism: the D-dimer only means something after the score is low. One habit does not carry over. ADvISED used a fixed 500 ng/mL cutoff, and in a retrospective study of 5,818 ED patients an age-adjusted cutoff raised specificity from 72.7% to 78.1% while sensitivity fell from 97.9% to 93.8%, a drop that was not statistically significant [8]. A 2025 pooled analysis of three prospective cohorts (4,907 patients in 12 centers, 10.3% with an aortic syndrome) compared five score and D-dimer protocols, age-adjusted cutoffs included, and found sensitivities from 97.6% to 99.4% [9]. No management trial has tested the age-adjusted cutoff, and ADvISED validated the fixed one, so use 500 ng/mL.

Which Image, and When Ultrasound Helps

CT is the recommended first image (Class 1, Level C-LD); transesophageal echocardiography and MRI are reasonable alternatives (Class 2a) [3]. The guideline says ECG-synchronized CT should be considered when the proximal aorta and coronary ostia need a clean picture [3].

Bedside echocardiography rules in better than it rules out. In an ADvISED substudy of 839 patients, direct signs such as an intimal flap had a specificity of 97.4% but a sensitivity of 45.2% [10]. An ADD-RS of 0 or 1 with no aortic signs on focused ultrasound still had a failure rate of 1.9%; adding a negative D-dimer brought it to 0% (95% CI 0% to 1.2%) [10]. Use the same probe to look for a flap, a dilated root, and pericardial fluid, and treat a normal scan as one input among several.

First-Hour Heart Rate and Blood Pressure

The 2022 ACC/AHA guideline sets out initial management in five recommendations [3]:

• Anti-impulse therapy with an arterial line, in an ICU setting (Class 1).
• Targets: systolic pressure below 120 mm Hg, or the lowest pressure that keeps end-organ perfusion, and a heart rate of 60 to 80 (Class 1, Level C-LD).
• An IV beta blocker first, such as esmolol, metoprolol, or labetalol (Class 1). If beta blockers are contraindicated, an IV non-dihydropyridine calcium channel blocker is reasonable for rate control (Class 2a).
• An IV vasodilator only after the beta blocker, if pressure is still high (Class 1). Starting a vasodilator first risks compensatory tachycardia.
• Pain control as needed to help the hemodynamics (Class 1, expert opinion). IV opiates work. The guideline cautions against IV NSAIDs such as ketorolac, citing hypertension and kidney injury.

Use beta blockers cautiously in acute aortic regurgitation, heart block, or bradycardia [3]. No randomized trial has tested any of these targets; the guideline says the evidence is small single-center studies and clinical experience [3].

The 2024 ESC guideline asks for a systolic pressure below 120 and a heart rate of 60 or less, with labetalol named as a first choice [11]. If your order set says "heart rate under 60," it follows the European target or the 2010 U.S. guideline that the 2022 document replaced [12].

Type A Means the Surgeon Now

For suspected or confirmed type A dissection, the guideline recommends emergency surgical consultation and immediate surgery (Class 1, Level B-NR) [3]. Transfer from a low-volume to a high-volume aortic center is reasonable for a patient stable enough to move (Class 2a) [3]. In registry data the guideline cites, surgical mortality fell from 25% to 18% between 1995 and 2013, while mortality with medical management stayed at 57% [3].

Key Takeaways

• An ADD-RS of 0 or 1 with a D-dimer below 500 ng/mL had a 0.3% failure rate in ADvISED. An ADD-RS of 2 or 3 goes to CT angiography with no D-dimer.
• In Sweden, 7 of 16 missed aortic syndromes were worked up as acute coronary syndrome. Check both arm pressures and the pain onset before antithrombotics.
• Under the 2022 ACC/AHA guideline, target a heart rate of 60 to 80 and a systolic pressure below 120 mm Hg, beta blocker first.
• A negative focused echo does not rule out dissection: direct signs had 45.2% sensitivity.

FAQ

Can a negative D-dimer rule out aortic dissection?

Only when the aortic dissection detection risk score is 0 or 1. In the ADvISED study, that combination with a D-dimer below 500 ng/mL had a failure rate of 0.3% [5]. With a score of 2 or 3, image the aorta whatever the D-dimer shows.

What are the heart rate and blood pressure goals in acute aortic dissection?

The 2022 ACC/AHA guideline targets a systolic pressure below 120 mm Hg, or the lowest pressure that keeps end-organ perfusion, and a heart rate of 60 to 80 [3]. The 2024 ESC guideline uses a systolic pressure below 120 and a heart rate of 60 or less [11]. No randomized trial has tested either target.

Why give a beta blocker before nicardipine or nitroprusside?

A vasodilator given first can cause compensatory tachycardia, which adds force against the injured aortic wall [3]. The guideline recommends an IV beta blocker first and a vasodilator only if pressure stays above target [3]. If beta blockers are contraindicated, an IV non-dihydropyridine calcium channel blocker can control the rate.

Dr. Chet's Take

I have practiced emergency medicine for more than 25 years at a Level I academic trauma center, and this article gets the hard part right. Aortic dissection rarely hides because nobody has heard of it. It hides inside the chest pain pathway, where the ECG gives the team something satisfying to treat and the aspirin goes in at triage. My addition is about that triage step. The order set fires before a physician has seen the patient, so the questions have to fire there too. Was the pain worst at the very start? Is there a pressure gap between the arms? Two questions and a second cuff cost a nurse less than a minute, and they are the cheapest aortic screen this department will ever own.

That being said, I would not turn the risk score into a reflex for every chest pain on the board. The score and the D-dimer were built for the patient you were already worried about. Run them on every chest pain in the department and you will scan far more people than you catch, and a positive D-dimer in a low-risk patient becomes its own reason to scan. The honest answer is that nobody has tested a heart rate of 60 to 80 against 60 or below in a trial, and I would not argue over the gap between 60 and 80 while the systolic pressure is still 180. Get the beta blocker in, get the rate down, and argue about the target later.

If you are the attending, consider putting both-arm pressures and the onset of pain into the chest pain protocol, then decide about aspirin. Write the score in your note, with the category that scored, so the next physician can see why a D-dimer was or was not sent. When the CT shows a type A dissection, the surgeon hears from you before the final report posts. If you work in a hospital without cardiac surgery, start the transfer call the minute the images show a flap, and keep the beta blocker running while the patient is in the air or on the road. If you teach residents, make them say the score out loud before they order the D-dimer. Rate control and the surgeon's call both belong in the first hour, at every hospital.

— Chester Shermer, MD, FACEP | Emergency Medicine, 25+ Years Clinical Experience | State Surgeon

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References

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2. Hansen MS, Nogareda GJ, Hutchison SJ. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection. Am J Cardiol. 2007;99(6):852-856. PubMed 17350381
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