Background/aim Acute aortic dissection (AAD) is a rare but fatal disease if left untreated. Symptoms are often similar to common conditions; therefore, the diagnostic strategy is important. We aimed to identify the atypical symptoms in a timely manner without putting patients at greater risk for undetected AAD. Materials and methods We conducted a retrospective observational study of 59 AAD patients with both atypical and typical symptoms from January 2012 to December 2016. Patients with atypical symptoms continuing more than 30 min underwent a D-dimer test and computed tomography (CT) or computed tomographic angiography (CTA). Results Of the 59 AAD patients, 22 were atypical. In the atypical group, the median delay time in our hospital was 3.1 h; average delay time after July 2015 was shorter than average delay time before June 2015 (16.59 ± 24.70 vs. 1.90 ± 0.57 h, P = 0.076). Conclusions For patients in the emergency department who are suspected of having AAD, incorporating atypical symptoms with high levels of D-dimer into a triage strategy could improve the efficiency of clinical decision making. Furthermore, essential education directed towards the recognition of the atypical symptoms of AAD for front-line physicians may aid in a timely diagnosis, as compared with the usual assessments in the emergency department.