Senator Lindsey Graham died on Saturday, July 11, at his home in Washington, D.C., at 71. Emergency responders had been called to his home for a cardiac arrest. His office initially described only a “brief and sudden illness”; the next day it released preliminary findings from the District’s chief medical examiner: aortic dissection due to arteriosclerotic cardiovascular disease.
Nothing in the public reporting suggests Graham’s care was delayed or that anyone missed anything. As emergency physician Jesse Pines wrote in Forbes within days of his death, this appears to be the disease at its most severe: a tear so catastrophic that the first symptom is collapse. In that version, no amount of awareness helps. The ambulance was already coming.
Which is precisely why the moment is worth using. There is another version of this disease: the one where the patient reaches the emergency department alive, with symptoms that look like something else. And there, awareness is everything, and there we are still failing.
The one-in-three problem
The aorta is the body’s largest artery: It leaves the heart, arcs through the chest, and runs down into the abdomen, feeding every major organ along the way. A dissection begins when the inner layer of that artery tears and high-pressure blood forces its way into the vessel wall, splitting it lengthwise. That opens a second, false channel inside the wall of the artery. It can cut off blood flow to the heart, the brain, the kidneys, the spinal cord, or the legs. The aorta itself can also rupture.
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Not all dissections are the same, and where the tear begins shapes both the danger and the treatment. A tear that begins in the ascending aorta, the section leaving the heart, is called Type A. Because it begins where the arteries supplying the heart and brain branch off, Type A is generally the more immediately dangerous form. It can cause sudden collapse and almost always requires emergency surgery. A tear confined to the descending aorta, farther down, is called Type B; it is also life-threatening, but uncomplicated cases are often managed first with intensive blood-pressure control rather than immediate open surgery. Public reporting hasn’t specified which type Graham had. His sudden collapse nevertheless shows how fast a dissection can turn fatal.
Aortic dissection is also, notoriously, a mimic. A pooled analysis of 12 studies covering more than 1,600 patients found an overall misdiagnosis rate of 33.8 percent. A Swedish cohort of 556 patients with Type A dissection found that 45 percent were initially misdiagnosed, and identified female sex as an independent predictor of getting it wrong. The disease is most often mistaken for a heart attack, a blood clot in the lungs, or a stroke.
Roughly one in three. That is the number worth sitting with.
This is not merely an academic failure of pattern recognition. Treat someone for a suspected heart attack and blood-thinning drugs are often part of the initial response. Give those same drugs to a person whose aorta is splitting, and you worsen the bleeding into the torn wall and complicate the emergency surgery they need. The misdiagnosis does not simply delay the right care. It delivers the wrong care.
John Ritter went to a Burbank hospital in 2003 with chest pain, nausea, and vomiting, and was treated for a myocardial infarction he was not having. He died that night at 54. Jonathan Larson, the composer of “Rent,” was sent home from one New York emergency department with food poisoning and from a second with a virus. He died on his kitchen floor at 35; the autopsy found a tear running roughly a foot down his aorta. State investigators faulted both hospitals and concluded that, had the diagnosis been made, effective treatment might have been possible.
Neither death is a story about a rare disease behaving unpredictably. Both are stories about a common presentation being read as something else.
The tools arrived, the reflex didn’t
For most of the twentieth century, aortic dissection was a diagnosis made at autopsy, because there was, effectively, no way to find one in a living patient. No CT scanners. No aortic surgery worth the name.
Today a CT angiogram of the aorta takes minutes and is highly accurate. Yet the reflex hasn’t kept pace with the technology: a review of autopsy-confirmed dissections spanning nearly six decades found that among patients already under medical care when they died, 63 percent had not been diagnosed before death, and that the miss rate barely budged between the earlier and later halves of the study, despite the arrival of modern imaging. The imaging is no longer the limitation. The consideration is.
Two beliefs keep the diagnosis from being considered at all, and both are wrong.
The first is that the pain announces itself. It usually doesn’t. In the International Registry of Acute Aortic Dissection (IRAD), the largest database of these patients in the world, sudden severe pain was the most common presenting complaint, but patients described it as sharp far more often than as the “tearing” or “ripping” sensation textbooks train clinicians to expect. The classic phrase is the exception, not the rule. Its absence reassures no one.
The second is that dissections only happen after the aorta has ballooned into a large aneurysm. For years that seemed intuitive. The evidence tells a different story. Among 591 patients with Type A dissection, 59 percent tore at an aortic diameter below 5.5 centimeters, under the threshold at which surgeons operate, and 40 percent below 5.0. The study’s conclusion was blunt: 5.5 centimeters is not a good predictor of who will dissect. “I’ve never been told I have an aneurysm” is not a reason to feel safe, and it is not a reason to stop considering the diagnosis when the symptoms fit.
Patients can ask the question themselves. If you arrive in an emergency department with sudden, severe chest, back, or abdominal pain, it is reasonable to ask: Has aortic dissection been considered? No clinician should take that as an insult. For some, that question may change the outcome.
What Graham’s case actually teaches
Everything so far has been about the dissections that reach a hospital in time to be caught or missed. Graham’s did not, and that points to the other half of the problem: prevention.
Arteriosclerotic cardiovascular disease, the second half of that medical examiner’s finding, is the same process that drives most heart attacks and strokes. Decades of plaque, inflammation, and above all high blood pressure stiffen and weaken the aortic wall. Chronic hypertension is the single largest risk factor for dissection. Blood-pressure control is not a lifestyle suggestion. It is aortic maintenance.
There is one thing almost anyone can do this week, at no cost, without a physician. Ask your family. Ask whether any blood relative has had an aortic aneurysm, a dissection, a bicuspid aortic valve, Marfan syndrome, or an unexplained sudden death before old age. Up to one in five people with a dissection or aneurysm in the chest portion of the aorta (the thoracic aorta) has an affected relative. Marfan syndrome carries up to 250 times the general population’s risk, and many first learn they have it only when the aorta tears. Black patients present nearly a decade earlier, on average, than white patients. This is also why surviving a dissection is a beginning rather than an end. Recovery often means lifelong imaging, strict blood-pressure control, sometimes additional surgery, and screening the relatives who share your aorta’s architecture. Most people have never asked these questions at a holiday table. The answers belong in a chart, not in a memory.
There is also a gap in the system meant to catch this early. Medicare covers a one-time screening ultrasound for the aorta where it runs through the belly, the abdominal aorta, in at-risk beneficiaries. It offers no equivalent one-time screening benefit for the thoracic aorta, the region involved in the deaths of Graham, Ritter, and Larson, even though we now know it can tear below 5 centimeters, at sizes no one would think to operate on. We screen the portion of the aorta a simple ultrasound can reach, and leave the portion it can’t to announce itself.
Awareness is not a soft intervention
A campaign called THINK AORTA is built around exactly this idea. It was created by patients and is endorsed by the American College of Emergency Physicians, the Society of Thoracic Surgeons, and the Society for Vascular Surgery. Its entire strategy fits on a poster: Think aorta, then get the CT. According to the campaign, those posters have been distributed to all 6,300 emergency departments in the country.
Simon Jones survived his dissection in 2020 after presenting with abdominal pain, not chest pain, not tearing, not textbook. He credits his survival to a physician who had seen the poster and, in his telling, had a hunch. She ordered a CT scan, which revealed the dissection.
That is what awareness looks like when it works. Not a viral graphic. A tired clinician at 2 a.m. asking one more question before discharge.
Every emergency the public now recognizes was once unfamiliar. Public-awareness campaigns taught one generation that “time is muscle” and another that “time is brain.” Aortic dissection is still waiting its turn, and Graham’s death will buy it perhaps a week on the front page before the miss rate settles back to where it has sat for fifty years.
We cannot diagnose what we do not consider. If a clinician pauses long enough to consider it, or a patient is unafraid to ask whether it has been considered, those few seconds are sometimes the entire margin between a survivor and an autopsy.
Laurel A. Coons is a scientist with a background in genomics and biomedical research. She completed her doctoral training in pharmacology and cancer biology at Duke University and conducted research at the National Institute of Environmental Health Sciences. Her work has focused on genomic regulation, endocrine signaling, and translating complex scientific data into insights relevant to medicine and patient care.
She shares professional updates on X at laurelcoons.
