Background: Acute aortic dissection (AD) is a life-threatening condition that remains challenging to diagnose and treat. MiR-133 plays important roles in aortic disease initiation and progression. However, its differential diagnostic value between acute myocardial infarction (AMI) and AD remains unclear. Methods: Serum samples were collected from healthy individuals, AMI and AD patients. Reverse transcription polymerase chain reaction (RT-PCR) was used to assess miR-133 expression. The differential diagnostic value values of miR-133 were analysed by statistical methods. Tissue samples were collected from AMI and AD patients, RT-PCR was used to test the expression of miR-133 and SOX4 mRNA, and Western blot and gelatin zymography were used to test the expression and activity of MMP-2, TIMP-1 and TIMP-2. In vitro, miR-133 mimics was transfected into VSMCs, and the biological function of miR-133 was evaluated by MTT assay, transwell assays, Western blot and gelatin zymography. A luciferase assay was used to explore whether SOX4-3'-UTR was a target gene of miR-133. Results: Compared with AMI patients, AD patients showed reduced serum miR-133 levels. In addition, ROC curve analysis shown that the sensitivity and specificity of serum miR-133 were 90.4% and 58.70% respectively for differential diagnoses between AD and AMI. In vitro, miR-133 up-regulation resulted in reduced VSMCs proliferation and invasion. In addition, an inverse correlation between miR-133 levels and SOX4 mRNA amounts was observed in AD tissues. More importantly, miR133 up-regulation resulted in reduced SOX4 expression, and the luciferase activity of the SOX4-3'-UTR plasmid was significantly suppressed by miR-133. Conclusion: MiR-133 has good application in differential diagnosis between AMI and AD. MiR-133 targets SOX4, thereby inhibiting VSMCs proliferation and migration and finally prevents the development of AD.