Delayed diagnosis of aortic dissection: the overlooked clues on chest X-ray
Dublin Core
Title
Delayed diagnosis of aortic dissection: the overlooked clues on chest X-ray
Subject
Acute chest pain, Acute aortic dissection, Chest radiography, Pleuritis, Differential diagnosis
Description
Abstract
Background Acute aortic dissection (AD) is a life-threatening vascular emergency requiring immediate intervention,
with mortality rates increasing by 1–2% per hour post-onset. The pathophysiology involves an intimal tear that
permits blood to enter the medial layer, forming a false lumen that may expand and compromise branch vessels
and end-organ perfusion. Current guidelines from the European Society of Cardiology (ESC), American College of
Cardiology (ACC), and American Heart Association (AHA) highlight the necessity of risk stratification based on clinical
features (e.g., tearing pain, pulse deficits), predisposing factors (e.g., hypertension), and D-dimer levels, followed by
confirmatory imaging with transthoracic echocardiography (TTE) or computed tomography angiography (CTA).
Despite advancements in imaging, chest radiography (CXR) remains underutilized; however, key findings—such as
mediastinal widening (≥5 cm at the aortic knob), abnormal aortic contour, and displaced intimal calcifications—can
offer critical diagnostic information.
Case report A young male patient presented with acute chest pain following strenuous exertion. Initial outpatient
evaluation, including complete blood count (CBC), liver function tests (LFTs), renal function tests (RFTs), cardiac
enzymes, and chest X-ray (CXR), yielded nondiagnostic results, leading to his discharge with analgesics. Three
days later, during a national holiday when outpatient clinics were closed, the patient returned to the emergency
department (ED) with persistent chest pain. A meticulous review of the initial CXR by the emergency physician
revealed mediastinal widening (measuring 8.5 cm) and an abnormal contour of the aorta. Subsequent emergency
computed tomography angiography (CTA) confirmed the diagnosis of a Stanford type B aortic dissection.
Conclusions This case underscores two critical learning points: (1) the diagnostic pitfalls associated with atypical
early presentations of aortic dissection, and (2) the often underappreciated value of meticulous interpretation of chest
X-rays in the evaluation of acute chest pain, particularly when initial studies yield unremarkable results. The three-
day diagnostic delay emphasizes the necessity of maintaining a high index of suspicion for aortic dissection, even in
young patients lacking classic risk factors.
Keywords Acute chest pain, Acute aortic dissection, Chest radiography, Pleuritis, Differential diagnosis
Background Acute aortic dissection (AD) is a life-threatening vascular emergency requiring immediate intervention,
with mortality rates increasing by 1–2% per hour post-onset. The pathophysiology involves an intimal tear that
permits blood to enter the medial layer, forming a false lumen that may expand and compromise branch vessels
and end-organ perfusion. Current guidelines from the European Society of Cardiology (ESC), American College of
Cardiology (ACC), and American Heart Association (AHA) highlight the necessity of risk stratification based on clinical
features (e.g., tearing pain, pulse deficits), predisposing factors (e.g., hypertension), and D-dimer levels, followed by
confirmatory imaging with transthoracic echocardiography (TTE) or computed tomography angiography (CTA).
Despite advancements in imaging, chest radiography (CXR) remains underutilized; however, key findings—such as
mediastinal widening (≥5 cm at the aortic knob), abnormal aortic contour, and displaced intimal calcifications—can
offer critical diagnostic information.
Case report A young male patient presented with acute chest pain following strenuous exertion. Initial outpatient
evaluation, including complete blood count (CBC), liver function tests (LFTs), renal function tests (RFTs), cardiac
enzymes, and chest X-ray (CXR), yielded nondiagnostic results, leading to his discharge with analgesics. Three
days later, during a national holiday when outpatient clinics were closed, the patient returned to the emergency
department (ED) with persistent chest pain. A meticulous review of the initial CXR by the emergency physician
revealed mediastinal widening (measuring 8.5 cm) and an abnormal contour of the aorta. Subsequent emergency
computed tomography angiography (CTA) confirmed the diagnosis of a Stanford type B aortic dissection.
Conclusions This case underscores two critical learning points: (1) the diagnostic pitfalls associated with atypical
early presentations of aortic dissection, and (2) the often underappreciated value of meticulous interpretation of chest
X-rays in the evaluation of acute chest pain, particularly when initial studies yield unremarkable results. The three-
day diagnostic delay emphasizes the necessity of maintaining a high index of suspicion for aortic dissection, even in
young patients lacking classic risk factors.
Keywords Acute chest pain, Acute aortic dissection, Chest radiography, Pleuritis, Differential diagnosis
Creator
Yao Chen1
, Wenjin Wang2
, Lian Lin3
and Zhankai Tang2*
, Wenjin Wang2
, Lian Lin3
and Zhankai Tang2*
Date
2025
Contributor
Peri Irawan
Format
PDF
Language
ENGLISH
Type
TEXT
Files
Collection
Citation
Yao Chen1
, Wenjin Wang2
, Lian Lin3
and Zhankai Tang2*, “Delayed diagnosis of aortic dissection: the overlooked clues on chest X-ray,” Repository Horizon University Indonesia, accessed April 20, 2026, https://repository.horizon.ac.id/items/show/13267.