Acute aortic dissection (AD) is a highly lethal cardiovascular emergency characterized by sudden, severe tearing chest pain, necessitating prompt intervention. This case report describes an exceptionally atypical presentation of AD in a young male patient, who exhibited neither the classic symptoms—such as pulse deficits or pain migration—nor the traditional risk factors, including hypertension or a history of connective tissue disorders.Upon initial evaluation at a general internal medicine clinic, differential diagnoses including pneumothorax, pneumonia, and myocardial injury were systematically excluded through laboratory tests and chest radiography. Consequently, a plausible initial diagnosis of pleuritis or costochondritis was made, considering the patient’s age and post-exertional pain.A critical diagnostic pivot occurred during an emergency reevaluation, wherein emergency physicians adhered to the “rule-out worst-first” principle, a cornerstone of acute care medicine. This approach emphasizes the systematic exclusion of immediately life-threatening conditions, such as acute coronary syndrome, pulmonary embolism, AD, and tension pneumothorax, prior to contemplating benign etiologies.This case illustrates three crucial lessons: (1) acute aortic dissection may present atypically in younger patients without classic features; (2) “normal” initial investigations do not preclude the possibility of aortic pathology; and (3) the reinterpretation of chest radiographs, particularly with adjustments to the mediastinal window, can unearth critical findings—including mediastinal widening greater than 8 cm and abnormal aortic contour—even when initially overlooked. These insights advocate for heightened clinical vigilance and a comprehensive diagnostic approach in similar cases.This case underscores clinicians’ imperative to personally review imaging beyond reports, particularly in emergencies. Key requirements include: (1) systematic analysis of all image planes/windows, focusing on high-risk areas (mediastinum/aortic contour); (2) correlating findings with clinical presentation; and (3) maintaining vigilance for life-threatening conditions. The emergency physicians’ meticulous re-evaluation—adjusting window settings to identify initially missed aortic abnormalities—proved lifesaving and should become standard practice, especially for atypical presentations. We advocate: mandatory secondary image review for high-risk cases, structured acute chest pain interpretation checklists, and quality programs tracking “second-look” diagnostic yields. The axiom “no accurate diagnosis, no effective treatment” encapsulates the ethical obligation of diagnostic diligence, particularly when managing young patients with persistent symptoms or clinical-imaging discrepancies. This approach balances thoroughness with efficiency in time-sensitive settings.
Despite significant advancements in medical knowledge, diagnostic challenges persist in the realm of aortic dissection (AD). Contemporary data from the International Registry of Acute Aortic Dissection (IRAD) indicate a misdiagnosis rate ranging from 14 to 39%, even within modern healthcare systems [6], Alarmingly, undiagnosed cases are associated with a 24-hour mortality rate as high as 50% [3]. Recent analyses from IRAD suggest that early hospital mortality remains at 59% [7], Although there has been an observed increase in incidence, this trend is likely indicative of enhanced diagnostic capabilities and improved public health awareness, rather than a genuine epidemiological shift. This apparent rise in incidence may reflect better case ascertainment owing to: (1) the widespread availability of computed tomography (CT), (2) the implementation of standardized diagnostic protocols, and (3) increased public education regarding acute chest pain. However, these statistics may still underestimate the true burden of the disease, as sudden pre-hospital deaths—particularly in younger patients—are often excluded from registry data. The persistently high mortality rates underscore the urgent need for: (1) refined risk-stratification tools, (2) enhanced education for emergency physicians regarding atypical presentations, and (3) the establishment of systems that ensure rapid access to imaging. Implementing these measures could help bridge the critical gap between diagnostic potential and clinical reality.
The persistently high rates of misdiagnosis in aortic dissection (AD) can be attributed to a complex interplay of factors: (1) clinical heterogeneity, which ranges from classic presentations characterized by “tearing” pain to completely asymptomatic cases; (2) cognitive biases, including diminished clinical suspicion and premature diagnostic closure; and (3) systemic issues, such as non-standardized workflows and suboptimal utilization of diagnostic tests. Emergency departments—where approximately 70% of AD cases first present—exemplify this diagnostic challenge, as physicians often anchor their assessments on acute coronary syndrome (ACS) when faced with chest pain complaints, despite the prevalence of AD being only 1–3% within this patient population [8]. While the “common-first” heuristic generally facilitates efficient decision-making, its uncritical application in the context of vascular emergencies poses significant risks. Three critical gaps have been identified: (a) an overreliance on atypical presentations to rule out AD, (b) underutilization of available imaging modalities (e.g., neglecting mediastinal assessment on initial chest X-ray), and (c) delays in specialty consultation. Addressing these issues necessitates the implementation of cognitive de-biasing training in conjunction with clinical decision support systems that incorporate the Aortic Dissection Detection Risk Score (ADD-RS) within electronic health records.
Aortic dissection remains a frequently misdiagnosed condition, despite its life-threatening nature. Key strategies to address this issue include: (1) enhancing physician education regarding atypical presentations, (2) implementing standardized protocols that integrate the Aortic Dissection Detection Risk Score (ADD-RS) and D-dimer testing, and (3) ensuring rapid access to computed tomography angiography (CTA) and transesophageal echocardiography (TEE). The potential of artificial intelligence (AI) in this domain is promising; recent studies have shown that AI can achieve sensitivity rates of 89–94% in detecting subtle radiographic signs when utilized in conjunction with picture archiving and communication systems (PACS) [9]. Future research should prioritize AI-assisted multi-modal analysis, incorporating electrocardiography (ECG), chest X-rays (CXR), and biomarker assessments [10]. These methodologies have the potential to enhance early detection while preserving diagnostic accuracy. This case underscores the urgent need for increased vigilance in young patients presenting with non-classical symptoms.