Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes

Nazerian, Peiman; Müeller, Christian; Vanni, Simone; Soeiro, Alexandre de Matos; Leidel, Bernd A.; Cerini, Gabriele; Lupia, Enrico; Palazzo, Andrea; Grifoni, Stefano; Morello, Fulvio

doi:10.1093/eurheartj/ehz207

Cited by 46 publications

(46 citation statements)

References 22 publications

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“…25 A multicentre prospective observational study including 839 patients (very lowquality evidence, downgraded for risk of bias and indirectness) showed moderate diagnostic accuracy (sensitivity 0.60, 95% confidence interval [CI] 0.51-0.68; specificity 0.85, 95% CI 0.83-0.88) for assessment of aneurysmal dilation of the aortic root. 26 Bedside ultrasound is operator dependent; therefore, the diagnostic accuracy may vary depending on the level of training. However, it is reasonable to examine those who are presenting with symptoms suggestive of AAS for the presence of an abdominal or thoracic aortic aneurysm in the visible portions of the aorta.…”

Section: Risk Factorsmentioning

confidence: 99%

“…A single-centre study of 839 patients (very low-quality evidence, downgraded for risk of bias and indirectness) suggests that bedside ultrasound is capable of diagnosing aortic regurgitation in AAS (sensitivity 0.1, 95% CI 0.06-0.16; specificity 0.93, 95% CI 0.91-0.95). 26 Diagnostic accuracy of bedside ultrasound for aortic regurgitation may vary between providers. This variation is also seen with clinical examination.…”

Section: High Pretest Probabilitymentioning

confidence: 99%

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Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

Ohle

Yan

Yadav

et al. 2020

CMAJ

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cute aortic syndrome (AAS) is a life-threatening emergency, accounting for 1/2000 presentations of acute chest or back pain to the emergency department. 1 It is a clinical spectrum of diagnoses including aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer at any location along the aorta. 1 The incidence of AAS is about 3 per 100 000 persons. 2,3 Many physicians do not consider AAS in their initial differential diagnosis, which is in part why 25% of patients with AAS are not diagnosed with the condition until 24 hours after presenting to the emergency department. 4 Prognosis is most favourable when patients are treated early, while they are clinically stable. Mortality follows a linear increase with diagnostic delay and can be as high as 2% per hour of delay. 5 The misdiagnosis rate during the initial emergency department visit for AAS (i.e., patient admitted for an alternative diagnosis and later diagnosed as AAS; discharged from the emergency department and presenting again with a diagnosis of AAS; or diagnosed on postmortem examination) is estimated to be as high as 38%. 4,6-16 Patients with suspected AAS are typically investigated with electrocardiogram (ECG)-gated contrast-enhanced computed tomography (CT). 2 Current use of this investigation in patients with a clinical suspicion for AAS is inefficient. 17,18 The unnecessary use of CT leads to a direct increase in health care costs but also an increase in contrast-associated complications (e.g., allergic reactions), increased length of emergency department stay or incidental findings requiring further follow-up, additional im aging and increased stress or anxiety for the patient. 17 Use of CT in a low-prevalence population can result in an increase in false-positives, which can lead to further testing, unnecessary transfer and even surgical intervention. 19 There are 2 high-quality guidelines related to the diagnosis of AAS, from the American Heart Association (2010) and the European Society of Cardiology (2014). 20,21 However, there is still considerable variation in how clinicians investigate for AAS in Canada. 17 This variation is likely multifactorial but may be a result of lack of key stakeholder involvement in the development of the guidelines or the difference in threshold for investigation within the Canadian health care system. 22,23 The aims of this guideline are to update the available guideline recommendations with current evidence; include key stakeholders to allow interpretation of the evidence in context of values and preferences; and make practice recommendations that are applicable to the Canadian health care system. The full guideline, including supplemental documents, is available at Appendix 1

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Section: Risk Factorsmentioning

confidence: 99%

Section: High Pretest Probabilitymentioning

confidence: 99%

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

Ohle

Yan

Yadav

et al. 2020

CMAJ

View full text Add to dashboard Cite

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“…Currently, with the newest imaging technology, TTE sensitivity and specificity have been improved in the diagnosis of AD [14]. Although trans-esophageal echocardiography (TEE) is the better technique, in many studies TTE has been suggested as the initial imaging in the emergency setting because of its availability and rapidity in the diagnosis of AD [11, 15, 16]. In our case, AD was diagnosed by TTE.…”

Section: Discussionmentioning

confidence: 86%

A Case of Aortic Dissection Presenting with Atypical Symptoms and Diagnosed with Transthoracic Echocardiography

Solhjoo

Swarup

Makaryus

2019

Case Reports in Radiology

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We present a case of an extensive aortic dissection (AD) identified in a woman with atypical symptoms. Transthoracic echocardiography (TTE) allowed the identification of an intimal flap in multiple locations and resulted in rapid diagnosis and treatment. In most cases, CT angiography is the imaging modality of choice for diagnosis of AD. TTE is rapid and accurate and can be used in kidney failure. Our case highlights the important role of bedside echocardiography in the diagnosis of AD, especially in the patient with a typical symptoms in whom this diagnosis of AD may not be entertained and actually missed leading to negative and possibly deadly consequences.

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“…A follow-up approach was used for pragmatic case adjudication based on 30-day outcomes. This method is routinely applied in diagnostic studies of cardiovascular emergencies in the ED such as pulmonary embolism and acute coronary syndromes and has been used in a previous multicenter study of AASs 12,[28][29][30][31][32] . As compared to our previous work, the timeline of the follow-up was extended from 14 to 30 days, in order to fully cover both the acute and subacute phases of AASs.…”

Section: Discussionmentioning

confidence: 99%

Prospective diagnostic accuracy study of plasma soluble ST2 for diagnosis of acute aortic syndromes

Morello

Bartalucci

Bironzo

et al. 2020

Sci Rep

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Acute aortic syndromes (AASs) are difficult to diagnose emergencies. Plasma soluble ST2 (sST2), a prognostic biomarker for heart failure, has been proposed as a diagnostic biomarker of AASs outperforming D-dimer, the current diagnostic standard. We performed a prospective diagnostic accuracy study of sST2 for AASs in the Emergency Department (ED). In 2017-2018, patients were enrolled if they had ≥1 red-flag symptoms (chest/abdominal/back pain, syncope, perfusion deficit) and a clinical suspicion of AAS. sST2 was detected with the Presage ® assay. Adjudication was based on computed tomography angiography (CTA) or on diagnostic outcome inclusive of 30-day follow-up. 297 patients were enrolled, including 88 with AASs. The median age was 67 years. In 162 patients with CTA, the median sST2 level was 41.7 ng/mL (IQR 29.4-103.2) in AASs and 34.6 ng/mL (IQR 21.4-51.5) in alternative diagnoses (P = 0.005). In ROC analysis, the AUC of sST2 was 0.63, as compared to 0.82 of D-dimer (P < 0.001). Sensitivity and specificity values of sST2 associated with different cutoffs were: 95.5% and 10.8% (≥12 ng/mL), 84.1% and 29.7% (≥23.7 ng/mL), 35.2% and 85.1% (≥66.5 ng/mL). Results were similar in the full cohort. In conclusion, in patients from a European ED, plasma sST2 provided modest accuracy for diagnosis of AASs.Acute aortic syndromes (AASs), which include acute aortic dissection (AAD), intramural aortic hematoma (IMH), penetrating aortic ulcer (PAU) and spontaneous aortic rupture (SAR), are severe cardiovascular emergencies affecting 5-10 per 100.000 individuals a year 1 . A conclusive diagnosis of AASs requires advanced aortic imaging, typically computed tomography angiography (CTA), which uses ionizing radiations and may cause contrast-induced nephropathy and anaphylaxis. However, selection of the right patient to image with CTA is cumbersome, because AASs present with unspecific symptoms such as truncal pain, syncope, neurological deficits and hindlimb ischemia. These are leading causes of Emergency Department (ED) visits worldwide, and most patients with these symptoms are affected by more common conditions, such as acute coronary syndromes, gastrointestinal diseases and muscle-skeletal pain. Hence, the misdiagnosis rate of AASs is high, affecting clinical outcomes 2-4 . Increasing use of CTA in EDs has led to a high number of CTA exams requested for suspected AAS turning out negative, but has not substantially changed misdiagnosis rates, indicating that pre-test patient selection remains a key node 5-7 . Development of reliable diagnostic biomarkers discriminating AASs could positively impact on their diagnostic workup, as for other cardiovascular emergencies such as acute coronary syndromes and pulmonary embolism 8,9 . So far, potential biomarkers of AASs have been searched for within aortic layers (e.g. smooth muscle myosin, soluble elastin fragments, calponin, CD40 ligand), within inflammation/remodeling pathways (e.g. matrix metalloproteinases) and within coagulation processes mobilized by blood exposure to non-endo...

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Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes

Cited by 46 publications

References 22 publications

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

Diagnosing acute aortic syndrome: a Canadian clinical practice guideline

A Case of Aortic Dissection Presenting with Atypical Symptoms and Diagnosed with Transthoracic Echocardiography

Prospective diagnostic accuracy study of plasma soluble ST2 for diagnosis of acute aortic syndromes

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