Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room

Abstract

BackgroundInitial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.MethodsWe conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.ResultsAn IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01–6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14–36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39–9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).ConclusionsWI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.

Diffusely Elevated ST Segments on Electrocardiography

“…In rare cases, a combination of atypical clinical features may mask aortic dissection; such delayed diagnosis could result in the patient's death. [1][2][3][4] Our patient presented with fever, pericardial effusion, and diffuse ST-segment elevation on ECG, a combination of which strongly suggested acute pericarditis. Although up to 30% of patients with acute aortic dissection have pericardial effusion (sometimes with tamponade), 5 acute pericarditis with a small amount of pericardial effusion is rare as an initial manifestation of aortic dissection.…”

“…1,2 Walk-in presentation to the emergency department was also a significant predictor of delayed diagnosis. 3,4 In addition to acute pericarditis, our patient walked into the emergency department, with fever and systolic blood pressure of 130 mm Hg. He also visited his primary care physician before coming to the emergency department.…”

Two Intriguing Cases of Stanford Type A Acute Aortic Dissection

“…AADs are frequently mistaken for other etiologies that cause chest pain, the most common being acute coronary syndromes. The incidence of initial miss diagnosis is up to 40% and may be more common when the ascending aorta is involved [12,13]. Errors in diagnosis delay proper treatment and can lead to inappropriate therapies (e.g., antithrombotic agents), which increases the risk of complications.…”

Ascending aortic dissection presented as inferior myocardial infarction: a clinical and diagnostic mimicry

“…One study on Stanford type-A AAD found that ∼50% and 37% of those patients have acute and chronic EKG changes, respectively 18. However, 27% of those patients have normal EKG, and only 8% have ST segment elevation (STE).…”