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Painless thoracic aortic dissection (TAD) and syncope
Patients with TAD do not always present with chest pain. In the International Registry of Aortic Dissection (IRAD) study, 2.2% of TAD cases were painless and approximately 13% of TAD cases presented with isolated syncope (i.e. NO PAIN). Other studies have shown that as many as 15% of TAD cases are painless.
Patients with TAD may present after a syncopal episode. The underlying pathophysiology of syncope is related to proximal rupture into the pericardium with resultant tamponade.
Add TAD to your differential diagnosis of unexplained syncope, especially in older folks and especially if a patient "looks bad" and you don't have a reason.