Frequency of and Inappropriate Treatment of Misdiagnosis of Acute Aortic Dissection

doi:10.1016/j.amjcard.2006.10.055

The American Journal of Cardiology

Volume 99, Issue 6, 15 March 2007, Pages 852-856

https://doi.org/10.1016/j.amjcard.2006.10.055 Get rights and content

Acute aortic syndrome (AAS) comprises acute aortic dissection, intramural hematoma, and penetrating ulcer of the aorta. The importance of accurate, rapid diagnosis and intervention for AAS is underscored by its clinical and epidemiologic overlap with acute coronary syndrome and by the risks of inappropriate treatment with antithrombotic agents. To explore these concerns, the recognition, management, and outcomes of AAS in the contemporary experience of a tertiary referral center were reviewed. Sixty-six consecutive patients with AAS admitted from January 2000 to December 2004 were identified, and their records reviewed. Misdiagnosis occurred in 39% (n = 26) and was associated with longer time to correct diagnosis (mean ± SEM 51 ± 12 vs 15 ± 5 hours, p = 0.003). Acute coronary syndrome was the most common misdiagnosis, resulting in inappropriate treatment with acetylsalicylic acid in 26 (100%), clopidogrel in 1 (4%), heparin in 22 (85%), and fibrinolytic agents in 3 (12%). Exposure to antithrombotic agents was associated with higher rates of major bleeding (38% vs 13%) and a trend toward greater in-hospital mortality (27% vs 13%) (p = 0.02 for combined end point). Antithrombotic agent administration was also associated with increased hemorrhagic pericardial fluid (50% vs 25%), hemorrhagic pleural effusion (15% vs 3%), and hemodynamic instability (30% vs 13%) (p = 0.02 for combined end point). In conclusion, AAS is frequently confused with acute coronary syndrome, leading to delayed diagnosis and clinically significant bleeding as a consequence of inappropriate treatment with antithrombotic agents.

Section snippets

Study population

The study was approved by the institutional research ethics board. Consecutive patients with AAS admitted to a tertiary care hospital from January 1, 2000, to December 31, 2004, were identified prospectively at presentation and/or retrospectively by review of inpatient unit admission logbooks, discharge summaries, and the hospital’s cardiovascular surgical database. Patients with definite AAS, confirmed by imaging, operative findings, or postmortem examination, were included in the study. AAS

Patient characteristics and initial diagnoses

Sixty-six patients (type A dissection: n = 43; type B dissection: n = 20; intramural hematoma: n = 3) were identified. Most (n = 52, 79%) were transferred from other hospitals. The mean age was 62 ± 2 years, and 50 (76%) were men. Baseline patient characteristics are listed in Table 1. There were no systematic differences between men and women with respect to baseline characteristics or subsequent outcomes. Findings on physical examinations and investigations are listed in Table 2. Blood

Discussion

Our findings suggest that in contemporary practice, AAS is frequently confused with ACS, leading to delayed diagnosis and inappropriate treatment with antiplatelet, antithrombin, and fibrinolytic therapies. Exposure to these agents is associated with hemodynamic instability, hemorrhagic pleural and pericardial effusions, increased hemorrhagic postoperative complications, and a trend toward increased mortality. These observations caution against the widespread and aggressive administration of

Acknowledgment

We are grateful to the Division of Cardiovascular Surgery, Saint Michael’s Hospital, for assistance with the surgical database.

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One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly.
An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased.
Optimized strategy to improve the outcomes of acute type A aortic dissection with malperfusion syndrome
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The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution.
Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (first stage) or an optimized strategy (second stage). In the second stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed, followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the first and second stages.
The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in the second stage vs 12.5% in the first stage; P < .01). In the second stage, the in-hospital mortality for MPS was decreased (10.2% vs 33.9%; P < .01). Moreover, the in-hospital mortality for MPS with symptom onset within 6 hours and beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in the second stage was comparable to that in patients without MPS (4.0% vs 2.4%; P > .05).
The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For patients with MPS symptom onset within 6 hours, immediate central repair is reasonable; for those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.
Misdiagnosis of Thoracic Aortic Disease Occurs Commonly in Emergency Transfers
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Acute aortic syndromes (AASs) are prone to misdiagnosis by facilities with limited diagnostic experience. We assessed long-term trends in misdiagnosis among patients transferred to a tertiary care facility with presumed AASs.
Our institutional transfer center database was queried for emergency transfers in patients with a diagnosis of AASs or thoracic aortic aneurysm between January 2008 and May 2018. There were 784 patients classified as emergency transfer for presumed AAS. Transferring diagnosis and actual diagnosis were compared through a review of physician notes and radiology reports from referring facilities and our center.
Mean age was 62 years, with 478 (61%) men. Differences in transferring diagnosis and actual diagnosis were identified in 89 patients (11.4%). Among misdiagnosed patients, the wrong classification of Stanford type A or type B dissections was identified among 24 patients (27%). No dissection was found in 23 patients (26%) with a referring diagnosis of aortic dissection. No signs of rupture were found in 18 patients (20%) transferred for contained/impending rupture. All misdiagnoses were secondary to misinterpretation of radiographic imaging, with motion artifacts in 14 (16%) and postsurgical changes in 22 (25%) being common sources of diagnostic error. Repeat scans were performed in 64 patients (72%) at our facility due to limited access to or suboptimal quality of outside imaging.
Although AASs misdiagnosis rates appear to be improving from the prior decade, there are opportunities for improved physician awareness through campaigns such as “Think Aorta.” Centralized web-based imaging may prevent the costly hazards of unnecessary emergency transfer.
D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction
2022, American Journal of Emergency Medicine
Acute aortic dissection (AAD) with concurrent ST-segment elevation myocardial infarction (STEMI) is relatively rare and sometimes overlooked. As D-dimer testing has been reported to have high sensitivity to diagnose AAD in a clinical scale, Aortic Dissection Detection Risk Score (ADD-RS), a point-of-care D-dimer analyzer capable of measuring in 10 min would be useful to deny AAD with concurrent STEMI. However, an optimal cut-off value of D-dimer in such population remains unclear. Therefore, the aim of this study was to elucidate the optimal D-dimer threshold in patients clinically diagnosed with STEMI.
This retrospective cohort study was conducted at two tertiary care centers between 2014 and 2019. Patients clinically diagnosed with STEMI who underwent serum D-dimer measurement on hospital arrival were included. The primary outcome was the diagnosis of AAD. The area under the receiver operating characteristic curve (AUROC) for D-dimer values to diagnose AAD was evaluated, particularly in patients with low to moderate risks of AAD (1 of ADD-RS). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with several cut-off values.
A total of 322 patients were included, and 28 were diagnosed with AAD. The AUROC for D-dimer to diagnose AAD was 0.970 (95% confidence interval: 0.948–0.993) in 262 patients with 1 of ADD-RS. If D-dimer ≥750 ng/mL was used as a cut-off value, sensitivity, specificity, PPV and NPV were 100%, 86.4%, 37.7%, and 100%, respectively. AAD could be denied in 209 (79.8%) patients using the cut-off value (D-dimer <750 ng/mL).
Serum D-dimer ≥750 ng/mL exhibited high sensitivity and NPV to diagnose AAD with concurrent STEMI, while the ADD-RS originally utilized ≥500 ng/mL as a cut-off for any suspected AAD. A point-of-care D-dimer measurement with the new cut-off would be useful to rule-out AAD among patients with STEMI.
Relation of Community-Level Socioeconomic Status to Delayed Diagnosis of Acute Type A Aortic Dissection
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Acute type A aortic dissection requires timely diagnosis and intervention. Previous studies have examined risk factors associated with delayed diagnosis; however, the effect of socioeconomic status (SES) has not been previously studied. Our study examined the impact of various SES measures on time to diagnosis. We examined time to diagnosis in consecutive cases of acute type A aortic dissection at a single institution. SES variables included race/ethnicity, Medicaid eligibility, and residence in a zip code with an increased Distressed Communities Index—an aggregate measure of community SES. Delayed diagnosis was defined as time to diagnosis in the upper quartile of the study population (>6.6 hours). A model predicting risk factors for delayed diagnosis was created using multivariable logistic regression. Our study included 124 patients with a median time to diagnosis of 3.36 hours (interquartile range [IQR] 1.83 to 6.63). A total of 92 patients were in the nondelayed cohort (median diagnosis time of 2.59 hours, IQR 1.49 to 4.18) and 32 patients were in the delayed cohort (median diagnosis time of 15.57 hours, IQR 9.34 to 28.75). In multivariable logistic regression, residence in a high–Distressed Communities Index zip code was associated with diagnostic delay (adjusted odds ratio [aOR] 5.108, p = 0.008). Patient age (aOR 0.944, p = 0.011), chest pain at presentation (aOR 0.099, p = 0.004), back pain at presentation (aOR 0.247, p = 0.012), evidence of malperfusion syndrome (aOR 0.040, p <0.001), history of hyperlipidemia (aOR 3.507, p = 0.026), and history of congestive heart failure (aOR 0.061, p = 0.036) were also significantly associated. In conclusion, our findings suggest community-level SES affects time to diagnosis in acute type A aortic dissection.
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Aortic dissection is a rare but potentially catastrophic condition. Misdiagnosis of aortic dissection is not uncommon as symptoms can overlap with other diagnoses.
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A total of 12 studies with were included with 1663 patients. The overall rate of misdiagnosis of aortic dissection was 33.8%. The proportion of patients presenting with chest pain, back pain and syncope were 67.5%, 24.8% and 6.8% respectively. The proportion of patients with pre-existing hypertension was 55.4%, 30.5% were smokers while the proportion of patients with coronary artery disease, previous cardiovascular surgery or surgical trauma and Marfan syndrome was 14.7%, 5.8%, and 3.7%, respectively. Factors related to misdiagnosis included the presence of symptoms and features associated with other diseases (such as acute coronary syndrome, stroke and pulmonary embolism), the absence of typical features (such as widened mediastinum on chest X-ray) or concurrent conditions such congestive heart failure. Factors associated with more accurate diagnosis included more comprehensive history taking and increased use of imaging.
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MiscellaneousFrequency of and Inappropriate Treatment of Misdiagnosis of Acute Aortic Dissection

Section snippets

Study population

Patient characteristics and initial diagnoses

Discussion

Acknowledgment

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Am J Cardiol

Prog Cardiovasc Dis

Chest

Chest

Ann Emerg Med

A simplified approach to the management of non-ST-segment elevation acute coronary syndromes

JAMA

Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: is the slope of the curve the shape of the future?

JAMA

The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease

JAMA

Miscellaneous
Frequency of and Inappropriate Treatment of Misdiagnosis of Acute Aortic Dissection