Objective To explore the relationship between the initial symptoms and prehospital delay among patients with acute aortic dissection, and to provide reference for conducting targeted prehospital health education. Methods A total of 488 patients with acute aortic dissection were selected, and their initial symptoms, general information, disease-related factors, prehospital related factors and prehospital time were collected to analyze the relationship between the initial symptoms and prehospital delay. Results The prehospital time of the participants was 135.5(48.3, 1735.5)min, the time of 253 patients (51.8%) was less or equal to 150 min, and the other 235 cases (48.2%) was more than 150 min (prehospital delay). The most frequent initial symptom was chest and back pain, which was suffered from by 146 cases (29.9%), and it was followed by chest pain with 124 cases (25.4%) and abdominal pain with 121 cases (24.8%). Logistic regression analysis showed that, self-perceived severity of the condition, chest and back pain were protective factors, while abdominal pain and limb numbness/pain were risk factors of prehospital delay in patients with acute aortic dissection (P<0.05, P<0.01). Conclusion Chest and back pain is the initial symptom in patients with acute aortic dissection, and their atypical symptoms of abdominal pain and limbs numbness/pain are the major factors resulting in prehospital delay. Therefore, it is necessary to strengthen disease related health education for the public, so as to help them adopt correct coping strategies in the early stage, seek medical treatment actively, and shorten the prehospital time ultimately.