Aortic Dissection vs Heartburn: How to Spot the Difference

When Chest Pain Signals a Catastrophe

When chest pain strikes, the mind often jumps to the most common culprits: a bout of indigestion, a muscle strain, or, more seriously, a heart attack. These are all valid concerns, and chest pain should never be ignored. However, there is a specific, unmistakable quality to the pain of a rare but often fatal condition that every person should be aware of: aortic dissection.

This occurs when a tear develops in the wall of the aorta, the body’s largest and most vital artery. The pain is not a squeeze or a dull ache; it is a sudden, excruciating sensation, often described as a tearing, ripping, or stabbing feeling that radiates from the chest directly into the back. When this particular pain pattern appears, it is a sign that a medical emergency is unfolding and that every second counts.

The Aorta

To understand aortic dissection, you must first understand the aorta. It is the body’s main superhighway for blood, arching up and over the heart before descending through the chest and abdomen. Its sole purpose is to receive a massive surge of blood from the left ventricle of the heart and distribute it, under high pressure, to every organ and limb in the body.

The aorta is a formidable vessel, but it has a surprisingly delicate structure. Its walls are composed of three distinct layers:

• The Tunica Intima: The smooth, inner lining that is in direct contact with the blood.
• The Tunica Media: A thick, muscular middle layer that provides the aorta with its strength and elasticity.
• The Tunica Adventitia: The durable outer layer that provides structural support and protection.

In a healthy aorta, these layers work in perfect harmony to withstand the immense pressure of each heartbeat. In an aortic dissection, this harmony is shattered.

What Happens in an Aortic Dissection

Aortic dissection begins with a small tear in the tunica intima, the innermost layer of the artery wall. This initial tear, often caused by chronic high blood pressure or a weakness in the wall, allows a forceful jet of blood to surge into the middle layer (tunica media). As blood rushes in, it separates the inner and outer layers of the aorta, creating a new, false channel for blood flow. This process is a dissection. ^[2]

The severity and treatment of an aortic dissection are entirely dependent on its location:

• Type A Dissection: This is the most dangerous type. The tear occurs in the ascending aorta, the section closest to the heart. Because of the direct pressure from the heart and the proximity to critical arteries supplying the brain and other organs, a Type A dissection is a surgical emergency that requires immediate intervention. ^[3]
• Type B Dissection: The tear occurs in the descending aorta, the section that travels through the chest and abdomen. While still very serious, Type B dissections are sometimes managed medically with aggressive blood pressure control, rather than immediate surgery.

Without treatment, the false channel created by the dissection can expand, potentially leading to a catastrophic rupture of the aortic wall, which is often fatal.

The Pain

While a heart attack typically presents as a crushing pressure or squeezing pain, the pain of an aortic dissection is unique and has a distinct signature. It is described as a sudden, sharp, and excruciating pain that is often so severe it is a person’s first experience of a pain of this magnitude. It is typically described as a:

• Tearing or ripping sensation.
• Stabbing or knife-like feeling.
• Pain that is maximal at onset, meaning it reaches its peak intensity almost immediately.

This pain typically begins in the center of the chest and radiates to the back, often traveling up between the shoulder blades. This radiation is a key differentiator from other types of chest pain. It occurs because the tear is extending along the length of the aorta. ^[5] The progression of the dissection down the aorta can even cause the location of the pain to shift over time. For example, if the dissection extends into the abdomen, the pain may migrate to the lower back or groin.

Other Warning Signs

While the pain is the hallmark symptom, a dissection can disrupt blood flow to any organ, leading to a host of other critical symptoms.

• Syncope or Fainting: If the dissection interrupts blood flow to the brain, it can cause a sudden loss of consciousness.
• Stroke-like Symptoms: Dissection can cause a stroke by blocking arteries that supply the brain. This may lead to weakness or paralysis on one side of the body, difficulty speaking, or changes in vision.
• Pulse or Blood Pressure Differences: A subtle but important sign is a significant difference in blood pressure between the two arms. This occurs if the dissection extends into an artery that supplies one arm, disrupting blood flow. ^[6]
• Sudden Weakness or Paralysis: If the dissection blocks blood flow to the spinal cord, it can cause sudden paralysis of the legs.

These symptoms, especially in conjunction with the characteristic pain, are a major red flag that an aortic dissection is underway.

Key Risk Factors

Aortic dissection does not happen at random. It is often the result of pre-existing conditions that weaken the aortic wall. The most significant risk factors are:

• Hypertension (High Blood Pressure): Uncontrolled high blood pressure is the single most common risk factor for aortic dissection. The constant pressure on the aortic wall weakens its layers over time, making a tear more likely.
• Connective Tissue Disorders: Genetic disorders like Marfan syndrome and Ehlers-Danlos syndrome affect the body’s connective tissues, including the elastic fibers in the aorta. This makes the aorta more fragile and susceptible to tearing, even at a younger age.
• Bicuspid Aortic Valve: The aortic valve typically has three leaflets. A bicuspid valve only has two, which can cause increased stress on the aortic wall and is a common risk factor for dissection.
• Smoking and Cocaine Use: Both smoking and cocaine use can cause a sudden, severe increase in blood pressure, which can trigger a dissection in a susceptible aorta.

Diagnosis and Treatment

Aortic dissection is a surgical emergency, and every minute that passes without treatment increases the risk of rupture and death. The mortality rate rises by 1% to 2% every hour that treatment is delayed.

Diagnosis is confirmed through advanced imaging, with the CT angiography (CTA) scan being the most common and rapid method. It provides a detailed, 3D view of the aorta, allowing doctors to precisely locate the tear and the extent of the dissection.

Treatment is dependent on the type of dissection:

• Type A Dissection: This requires immediate, open-heart surgery to repair the tear, replace the damaged section of the aorta with a synthetic graft, and restore blood flow.
• Type B Dissection: These can often be managed with medications to aggressively lower blood pressure and heart rate. However, if the dissection is expanding or causing organ damage, surgery or a less invasive endovascular procedure may be necessary.