How life can change in a heartbeat – when aortic dissections strike without warning

Posted: 06/11/2024

Four thousand people suffer aortic dissection in the UK each year and only 50% of them survive. Aortic dissection is a life-threatening condition that occurs when the inner layer of the aorta, the body's main artery, tears. Blood rushes through the tear, splitting the inner and middle layers of the aorta, which is known as a dissection. 

Aortic dissection is classified into two types based on the location of the tear in the aorta (the Stanford classification). Type A is the more common and dangerous type of aortic dissection, affecting the upper part of the aorta near the heart. It usually requires immediate surgery to repair. Type B aortic dissection affects the lower part of the aorta, known as the descending aorta. It is usually less dangerous than type A, and the risk of rupture is lower. Treatment for type B aortic dissection is often medical, such as controlling blood pressure with medication. 

Aortic dissection can occur without any warning signs. A fit and healthy person can suddenly suffer severe pain in the chest, back or abdomen, sometimes feeling like a ripping sensation and coming on out of nowhere. Men are statistically more likely to suffer aortic dissection than women and the most likely sufferer is a male in his fifties. 20% of people who suffer aortic dissection have a genetic disposition to it, meaning it runs in their family. It is believed that a basic weakness in the aortic wall, which can be inherited, causes most aortic dissections. In other cases, the stress from constant high blood pressure can weaken the aorta wall, leading to tear and dissection. 

The first line of investigation for a suspected aortic dissection is a CT scan of the chest and blood tests. Other forms of imaging may be used depending on what is available most quickly. 

Aortic dissection and negligence

With prompt diagnosis and surgery to repair the aorta, there is an approximate 80% survival rate from aortic dissection. It is survivable if it is considered and diagnosed quickly. The challenge, though, is achieving reliable diagnosis in the emergency department. Aortic dissection has very low incidence; for approximately every 1,000 patients seen in an emergency department with chest pain of some sort, probably less than three of them will have aortic dissection. 

Aortic dissection can also cause quite a confused presentation of complex transient symptoms, yet extremely time critical decisions must be made. One third of aortic dissections are misdiagnosed, with those patients paying the ultimate price with their lives, or surviving, but requiring lifelong surveillance to detect complications that may later require surgery. 

Alison Johnson, partner in the clinical negligence team at Penningtons Manches Cooper, comments: “The key to reducing death rates from aortic dissection must be educating emergency care doctors to recognise it, even if only as part of a differential diagnosis, to request CT scanning (or other imaging), and for waiting times for scanning to be reduced. In other words, reducing the timeline from presentation at the emergency department to having scan results to confirm or exclude the diagnosis. 

“It may well be considered negligent for the emergency team not to consider serious cardiac causes for chest pain, including aortic dissection, and not to enquire as to family history.  Tragically this does happen, and aortic dissections are misdiagnosed as heart attacks, angina, gastritis, sepsis, pulmonary embolisms, and even panic attacks. Scanning should be used early to make the diagnosis when aortic dissection is suspected and a comprehensive history taking is a vital part of that.” 

Case study

In the case of RCH v United Lincolnshire Hospitals NHS Trust, the estate of a deceased man received £570,000 following his death aged 35, from heart conditions. He presented at hospital with chest pains on two consecutive days, and although investigations were carried out, an X-ray was not reviewed appropriately, and a CT scan was not performed. The deceased suffered an aortic dissection, resulting in his death.

The executors for the deceased’s estate brought a clinical negligence claim against the NHS trust, alleging that it was negligent in failing to request an urgent CT scan, after the chest X-ray should have been reviewed and considered alongside the deceased’s clinical presentation. It was alleged that a scan was likely to have confirmed a diagnosis of aortic dissection, and the deceased would then have been transferred as an emergency to the cardiac surgery team elsewhere. 

On the balance of probabilities, the deceased would then have undergone surgery to repair the dissection in sufficient time to prevent the rupture of the aorta and to avoid his death. Negligence was admitted. The NHS trust admitted a negligent failure in relation to the interpretation of the chest X-ray and the failure to request a CT scan.

Return to news headlines