Aortic Dissection Missed in the Emergency Room — How These Malpractice Cases Get Built

Aortic dissection is one of the fastest-moving emergencies in all of medicine. The inner layer of the body's largest artery tears, blood forces its way into the wall of the vessel, and the tear can propagate in seconds — cutting off blood flow to the heart, the brain, the kidneys, or the legs, and threatening to rupture entirely. For the most dangerous form, a Type A dissection involving the ascending aorta, mortality climbs by roughly one to two percent for every hour the condition goes untreated. That is not a figure of speech. It is the reason a dissection that is recognized in the first hour is often survivable, and a dissection that is sent home as heartburn is often fatal.

It is also one of the hardest diagnoses to make, because it hides behind the symptoms of far more common problems — a heart attack, acid reflux, a pulled muscle, a stroke, a kidney stone. That combination of extreme lethality and a talent for imitation is exactly what makes a missed aortic dissection a recurring, and often catastrophic, source of malpractice litigation. This guide walks through how a dissection is supposed to be recognized in the emergency room, the patterns of failure that produce these cases, the time-stamped records that decide them, and what families should preserve when they believe a dissection was missed.

The Aortic Dissection Picture in U.S. Emergency Rooms

Acute aortic dissection is uncommon relative to the flood of chest-pain visits an emergency department sees — estimates place it at roughly three to four cases per 100,000 people per year — but its rarity is part of the danger. Because most chest pain is not a dissection, the diagnosis is easy to leave off the list entirely. The classic presentation is a sudden, severe, "tearing" or "ripping" pain in the chest or between the shoulder blades, sometimes migrating as the tear extends. But many patients do not read from the textbook, and the pain can present as pressure, as abdominal pain, or as a neurologic event when the dissection reaches the arteries feeding the brain.

The result is a diagnosis that is missed at first contact far more often than it should be. Reviews of the literature report that only a minority of confirmed dissections — one widely cited range is roughly 15 to 43 percent — are correctly identified at the very first presentation, meaning a large share of patients are initially labeled with something else. The failure is rarely a lack of effort. It is the predictable consequence of a rare, imitative disease colliding with a fast, crowded environment.

The Time and Mortality Windows That Define the Stakes

Dissections are classified by which part of the aorta is involved. A Stanford Type A dissection involves the ascending aorta and is a surgical emergency — it usually requires an operation within hours. A Type B dissection is confined to the descending aorta and is frequently managed medically, at least initially, with aggressive blood-pressure control. The distinction matters enormously to the clock.

For an untreated Type A dissection, data from the International Registry of Acute Aortic Dissection (IRAD) is the reference point most experts return to: mortality rises on the order of one to two percent per hour in the early hours, and roughly half of untreated patients do not survive the first 48 hours. Every hour of diagnostic delay in the emergency department is therefore not a neutral wait — it is a measurable increase in the risk of death and of the complications, such as stroke or organ loss, that come with a propagating tear.

The Standard of Care: The 2022 ACC/AHA Guideline and the ADD-RS

The current national reference is the 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease, published jointly by the American College of Cardiology and the American Heart Association. It gives emergency clinicians a structured way to keep dissection on the table without sending every chest-pain patient to a CT scanner. The centerpiece for the emergency department is the Aortic Dissection Detection Risk Score (ADD-RS), a simple 0-to-3 tool that awards one point in each of three categories:

• High-risk predisposing conditions — for example, Marfan syndrome or other connective-tissue disease, a family history of aortic disease, a known aortic aneurysm or valve disease, or recent aortic manipulation.
• High-risk pain features — pain that is abrupt in onset, severe in intensity, or tearing or ripping in quality.
• High-risk exam findings — a pulse deficit or a blood-pressure differential between the arms, a new aortic-regurgitation murmur, or focal neurologic signs accompanying the pain.

The guideline pairs the score with a clear pathway. Patients who screen high-risk (ADD-RS of 2 to 3) should move directly to definitive imaging — CT angiography of the chest, abdomen, and pelvis. Patients at lower risk (ADD-RS of 0 to 1) can be further sorted with a D-dimer blood test: a result below the standard cutoff makes a dissection much less likely and can support holding off on imaging, while an elevated D-dimer points toward proceeding to CT angiography. This ADD-RS-plus-D-dimer strategy was validated prospectively in the ADvISED study and is now the framework a defense expert and a plaintiff's expert will both measure the ER's actions against.

The Diagnostic Workup That Should Happen

When a patient arrives with symptoms that could be a dissection, the standard emergency workflow builds on the guideline:

1. A history that asks the right questions. Onset (abrupt versus gradual), quality (tearing or ripping), migration of the pain, and any connective-tissue disease or family history of aortic disease are the details that populate the risk score.
2. An exam that looks for the tell-tale signs. Blood pressure should be measured in both arms, pulses checked in all four limbs, the heart auscultated for a new murmur, and a focused neurologic exam performed. A pulse deficit or an arm-to-arm blood-pressure difference is a classic and easily overlooked clue.
3. Risk stratification with the ADD-RS. The three categories are scored, and the number drives the next step rather than a gestalt impression.
4. D-dimer where the pathway calls for it. For lower-risk patients, the blood test helps decide who needs imaging.
5. CT angiography for definitive diagnosis. A chest X-ray may show a widened mediastinum, but a normal chest X-ray does not rule out a dissection — CT angiography (or, in the unstable patient, a bedside echocardiogram) is the test that confirms or excludes it.
6. Immediate specialist involvement. A confirmed Type A dissection is a surgical emergency requiring urgent cardiothoracic surgery consultation and blood-pressure control; the disposition is the operating room, not the waiting room.

Why Aortic Dissection Gets Missed

The single most dangerous trap is the overlap with a heart attack. A dissection can tear into the origin of a coronary artery and cause a genuine myocardial infarction, so the patient can have chest pain and an abnormal ECG and a rising troponin — a picture that looks exactly like an acute coronary syndrome. The clinician anchors on the common diagnosis and starts the standard heart-attack treatment. The problem is that the cornerstones of that treatment — anticoagulants and clot-dissolving thrombolytic drugs — can be catastrophic in a patient who is actually dissecting, accelerating the bleeding into the aortic wall.

Other common misdirections include attributing the pain to acid reflux or a muscle strain, treating a dissection that has reached the brain as a primary stroke, or working up flank pain as a kidney stone. Because each of these alternatives is far more common than a dissection, the anchoring is understandable — but the standard of care exists precisely to force the question "could this be a dissection?" before the more comfortable answer is accepted.

The Patterns of Failure

The heart-attack anchor

The chest pain and an abnormal ECG lock in a diagnosis of acute coronary syndrome, and the dissection is never considered. In the worst version, the patient receives blood thinners or thrombolytics that would be contraindicated if the dissection had been recognized.

The "it's just reflux" or "it's musculoskeletal" discharge

Sudden severe pain is attributed to a benign cause, the patient is given an antacid or a pain reliever, and no risk score, D-dimer, or imaging is documented. When the discharge diagnosis is a benign alternative and the record shows the tearing-pain description or a blood-pressure differential was present, the omission stands out.

The un-examined pulse and blood pressure

Blood pressure is taken in one arm only, pulses are not checked in all limbs, and a pulse deficit or arm-to-arm differential — one of the most specific physical clues — is never looked for and so is never found.

The ADD-RS that was never applied

The elements needed to score the patient are sitting in the history and exam, but no structured risk assessment is performed, and a patient who would have screened high-risk is instead managed on impression alone.

The falsely reassuring chest X-ray

A normal or near-normal chest X-ray is treated as proof the aorta is fine. Because a chest X-ray misses a meaningful fraction of dissections, stopping the workup there when suspicion remains is a recurring and preventable deviation.

The premature discharge

The patient is sent home without imaging, without specialist involvement, and without clear return precautions, only to return — or not return — with a completed dissection.

What the Records Show

Missed-dissection cases are won and lost on a small set of time-stamped entries, most of which live in the electronic medical record:

• Time of arrival (door time) and the chief complaint and pain description recorded at triage.
• Triage acuity assignment — was severe, abrupt-onset chest or back pain flagged as high acuity?
• The documented history — onset, quality, migration, and any connective-tissue disease or family history.
• Vital signs, including blood pressure in both arms, and whether pulses were checked in all limbs.
• Any recorded ADD-RS or equivalent risk assessment, and the differential diagnosis the physician wrote down.
• D-dimer order and result times where the pathway called for one.
• The time definitive imaging (CT angiography) was ordered, performed, and read — often the single most important interval.
• Any treatment given, including anticoagulants or thrombolytics started under a working diagnosis of heart attack.
• Consultation times for cardiology or cardiothoracic surgery.
• Discharge diagnosis, instructions, and return precautions if the patient was sent home — and any return-visit or autopsy records.

The cases get built in the gaps between these time stamps — the minutes and hours where the standard of care called for an action the chart shows never happened.

The Medical-Legal Read

What separates a defensible bad outcome from a provable deviation is usually buried in the timing and the omissions, and reading it takes both clinical and legal training. At The Alvarez Law Firm, Herb Borroto, M.D., J.D. (Medical-Legal Expert) reviews the emergency record the way a physician reads a chart — checking whether blood pressure was taken in both arms, whether the tearing-pain description was captured and acted on, whether the ADD-RS elements were present but never scored, and whether heart-attack treatment was started without dissection ever being ruled out. Alex Alvarez (Managing Partner, Board Certified Civil Trial Lawyer) then frames that record for a jury: not as hindsight, but as a series of measurable choices against a published national guideline. This combination — a doctor reading the medicine and a board-certified trial lawyer proving the case — is how a missed-dissection claim is tested before it is ever filed.

Proving Causation and Damages

In a missed-dissection case, causation is the battleground. The defense will argue the dissection was already unsurvivable by the time the patient arrived, or that the outcome would have been the same regardless of when it was diagnosed. To answer that, a cardiothoracic surgeon or emergency-medicine expert reconstructs the window: where the tear was when the patient first presented, whether timely CT angiography and surgery would more likely than not have changed the result, and how the delay affected the odds. The damages picture in these cases commonly includes:

• Past and future medical care, including surgery, intensive-care treatment, and long-term management of the aorta and any organ or neurologic injury.
• Lost wages and loss of future earning capacity when a working-age patient is left permanently disabled.
• Pain, suffering, and loss of enjoyment of life.
• Loss of consortium for a spouse.
• Wrongful-death damages when the dissection was fatal. See our guide to medical malpractice filing deadlines for the statute-of-limitations picture.

What Families Should Preserve

When you believe a family member's aortic dissection was missed or delayed in the ER, the first 30 to 90 days are when the records are most accessible:

• Request the full emergency-department record under the federal HIPAA right of access — not just the summary discharge document. The triage log, nursing notes, vital-sign flowsheet, and imaging time stamps are the critical detail.
• Ask specifically for the vital-signs flowsheet showing blood pressure in each arm and any imaging orders, reports, and the images themselves with their times.
• Preserve any 911 recording and EMS run report — the paramedic narrative often contains the original symptom-onset time and the first description of the pain.
• Save text messages or call logs that document when symptoms started and what was said at the visit.
• Note the name of every physician, nurse, and consultant involved.
• If the patient was transferred, request records from both facilities, and if the dissection was fatal, preserve any autopsy report — an autopsy frequently confirms the diagnosis that was missed in life.

Our guide to the medical records your lawyer needs walks through the broader request process, and our overview of the four elements of a malpractice claim explains what each case has to prove.

Frequently Asked Questions

Is a missed aortic dissection in the ER always malpractice?

No. A missed or delayed aortic dissection is malpractice only when the emergency room's care fell below the accepted standard and that failure caused harm the patient would otherwise have avoided. Aortic dissection is genuinely difficult to diagnose and can mimic other conditions, so the question is not whether it was missed but whether a reasonable ER, faced with the same findings, should have considered it and taken the next diagnostic step.

How is aortic dissection supposed to be diagnosed in the emergency room?

The 2022 ACC/AHA aortic disease guideline directs emergency clinicians to assess risk with the Aortic Dissection Detection Risk Score (ADD-RS), which scores predisposing conditions, pain features, and exam findings from 0 to 3. High-risk patients (a score of 2 to 3) should go directly to CT angiography; lower-risk patients can be further sorted with a D-dimer blood test before imaging. CT angiography of the chest, abdomen, and pelvis is the definitive test.

Why is aortic dissection so often mistaken for a heart attack?

A dissection can tear into the coronary arteries and actually cause a heart attack, and both produce sudden chest pain, so the ECG and the story can point toward acute coronary syndrome. The danger is that the standard heart-attack treatment — blood thinners and clot-busting drugs — can be catastrophic in a dissection. That overlap is exactly why the standard of care asks clinicians to keep dissection in the differential rather than anchoring on the more common diagnosis.

How long do I have to file a missed-aortic-dissection malpractice case?

The deadline depends on the state, and most states run a statute of limitations from when the injury was or should have been discovered, with an outer statute of repose. Because these clocks are short and pre-suit steps take time, families should confirm their state's deadline early rather than assume.

If You or a Family Member's Aortic Dissection Was Missed

Free, confidential case review. We work nationwide with families whose aortic-dissection care was delayed or whose dissection was misdiagnosed in the ER.

• Read about ER malpractice generally: Emergency Room Errors.
• Read about missed heart attack (the diagnosis dissection is most often mistaken for): Heart Attack Missed in the Emergency Room.
• Read about missed stroke: Stroke Missed in the Emergency Department.
• Read about missed sepsis: Sepsis Missed in the Hospital.

Free case review. No fees unless we recover compensation for you.

Sources

• Isselbacher EM, et al. — "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease." Circulation, 2022. ahajournals.org
• Nazerian P, et al. (ADvISED Investigators) — "Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes." Circulation, 2018. ahajournals.org
• Hagan PG, et al. — "The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease." JAMA, 2000. jamanetwork.com
• Levy D, Goyal A, et al. — "Aortic Dissection." StatPearls, National Library of Medicine (NCBI Bookshelf). ncbi.nlm.nih.gov
• American College of Emergency Physicians — Clinical policies on chest pain and suspected acute aortic syndrome. acep.org