Diagnostic performance of emergency transthoracic focus cardiac ultrasound in suspected acute type A aortic dissection

A 12-year Retrospective Cohort Study of Point-of-care Ultrasound and Aortic Dissection Risk Score in Type A Aortic Dissection

BACKGROUND

Aortic dissection (AD) is a vascular emergency with time-dependent mortality. Point-of-care ultrasound (POCUS) and AD risk score (ADRS) have been proposed as diagnostic tools to risk stratify patients and reduce time to diagnosis.

STUDY OBJECTIVE

We evaluate POCUS findings and ADRS in a retrospective cohort of patients with known type A AD. The objective of this study is to describe the prevalence of POCUS findings and ADRS in this population.

METHODS

This is a retrospective cohort study of patients with acute type A AD as confirmed on computed tomography scan over a 12-year period from 2008 to 2020, with a subgroup analysis of patients who received POCUS in the emergency department. ADRS was calculated and POCUS findings were reviewed. Descriptive statistics were used to describe the distribution of POCUS findings.

RESULTS

Ninety-one patients met inclusion criteria. POCUS was performed in 41 but only 35 had images of adequate quality for inclusion. Of the POCUS images available, 30/35 (86%) patients had a POCUS finding consistent with dissection and 5/35 (14%) had no findings on POCUS. Twelve percent (11/91) of patients had ADRS = 0. Two patients with ADRS = 0 received POCUS, and one patient had no findings on POCUS.

CONCLUSION

Although POCUS provides rapid information in the diagnosis of type A AD, 14% of patients with images available for review had no findings on POCUS. Of the whole cohort, 12% had an ADRS = 0. Further studies are needed to identify an optimal diagnostic pathway for this catastrophic disease.

Bedside-focused transthoracic echocardiography in acute atraumatic thoracic aortic syndrome: a systematic review and meta-analysis of diagnostic accuracy

The objective of this review is to assess the diagnostic accuracy of bedside-focused transthoracic echocardiography (TTE) in acute atraumatic thoracic aortic syndrome in adults. We performed a systematic review and meta-analysis of publications that described the use of bedside-focused TTE on adults presenting to the emergency care setting with suspected atraumatic thoracic aortic syndrome. Studies were identified using keyword and Medical Subject Heading searches on databases and grey literature, followed by abstract screening and study selection by two independent reviewers. Sixteen studies over six decades were included in the meta-analysis (n = 4569 patients). The prevalence of Type A thoracic aortic dissection was 11% (range 1.4-45.7%) and Type B dissection was 7% (range 1.8-30.55%). Type A dissection through direct visualisation of an intimal flap on TTE (i.e. direct sign) pooled sensitivity and specificity were 89% [95% confidence interval (CI), 82-94%] and 92% (95% CI, 88-95%) respectively. For Type B dissection, the pooled sensitivity was 65% (95% CI, 45-80%) and specificity was 100% (95% CI, 0.69-100%). TTE indirect signs for dissection showed a pooled sensitivity of 64% (95% CI, 5.2-98.2%) and specificity of 94% (95% CI, 92-96.1%) for aortic valve regurgitation, a pooled sensitivity of 92% (95% CI 54-99.2%) and specificity of 87% (95% CI, 62-97%) for thoracic aortic aneurysm and a pooled sensitivity of 39% (95% CI 33.8-45%) and a specificity of 94% (95% CI, 92-95%) for pericardial effusion. In this systematic review and meta-analysis, bedside-focused TTE has a good specificity for Type A and B dissection, but poor sensitivity for Type B, and unclear for intramural haematoma and penetrating aortic ulcer.

[Prehospital ultrasound in emergency medicine]

Small, portable hand-held ultrasound devices nowadays enable a widespread use of prehospital point-of-care ultrasound (pPOCUS), which has so far only been used hesitantly, especially in ground-based emergency services. Many critical or even life-threatening conditions or internal injuries can often be better diagnosed or ruled out using pPOCUS, which can enable faster and more suitable goal-directed treatment and hospital transport. This article critically discusses relevant data, clinical benefits, limitations and challenges to be overcome when using pPOCUS for the most important life-threatening situations and aims to call for intensifying training and the extensive use of pPOCUS.

Diagnostic Accuracy of Transthoracic Echocardiography for Acute Type A Aortic Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND

Transthoracic echocardiography (TTE) is currently recognized as the potential first-line imaging test for patients with suspected acute type A aortic syndrome (AAAS). Direct TTE sign for detecting AAAS is positive if there is an intimal flap separating two aortic lumens or aortic wall thickening seen in the ascending aorta. Indirect TTE sign indicates high-risk features of AAAS, such as aortic root dilatation, pericardial effusion, and aortic regurgitation. Our aim is to summarize the existing clinical evidence regarding the diagnostic accuracy of TTE and to evaluate its potential role in the management of patients with suspected AAAS.

METHODS

We included prospective or retrospective diagnostic cohort studies, written in any language, that specifically focused on using TTE to diagnose AAAS from databases such as PubMed, EMBASE, MEDLINE, and the Cochrane Library. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio [1], and hierarchical summary receiver-operating characteristic (HSROC) curve were calculated for TTE in diagnosing AAAS. We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria.

RESULTS

Ten studies (2886 patients) were included in the meta-analysis. The pooled sensitivity and specificity of direct TTE signs were 58% (95% CI, 38-76%) and 94% (95% CI, 89-97%). For any TTE signs, the pooled sensitivity and specificity were 91% (95% CI, 85-94%) and 74% (95% CI, 61-84%). The diagnostic accuracy of direct TTE signs was significantly higher than that of any TTE signs, as measured by the area under the HSROC curve [0.95 (95% CI, 0.92-0.96) vs. 0.87 (95% CI, 0.84-0.90)] in four studies.

CONCLUSIONS

Our study suggests that TTE could serve as the initial imaging test for patients with suspected AAAS. Given its high specificity, the presence of direct TTE signs may indicate AAAS, whereas the absence of any TTE signs, combined with low clinical suspicion, could suggest a lower likelihood of AAAS.

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study

OBJECTIVES

An aortic dissection (AoD) is a potentially life-threatening emergency with mortality rates exceeding 50%. While computed tomography angiography remains the diagnostic standard, patients may be too unstable to leave the emergency department. Investigators developed a point-of-care ultrasound (POCUS) protocol combining transthoracic echocardiography (TTE) and the abdominal aorta. The study objective was to determine the test characteristics of this protocol.

METHODS

This was an institutional review board-approved, multicenter, prospective, observational, cohort study of a convenience sample of adult patients. Patients suspected of having an AoD received a TTE and abdominal aorta POCUS. Three sonographic signs suggested AoD: a pericardial effusion, an intimal flap, or an aortic outflow track diameter measuring more than 35 mm. Investigators present continuous and categorical data as medians with interquartile ranges or proportions with 95% confidence intervals (CIs) and utilized standard 2 × 2 tables on MedCalc (Version 19.1.6) to calculate test characteristics with 95% CI.

RESULTS

Investigators performed 1314 POCUS examinations, diagnosing 21 Stanford type A and 23 Stanford type B AoD. Forty-one of the 44 cases had at least one of the aforementioned sonographic findings. The protocol has a sensitivity of 93.2% (95% CI 81.3-98.6), specificity of 90.9 (95% CI 89.2-92.5), positive and negative predictive values of 26.3% (95% CI 19.6-33.9) and 99.7% (95% CI 99.2-100), respectively, and an accuracy of 91% (95% CI 89.3-92.5).

CONCLUSIONS

The SPEED protocol has an overall sensitivity of 93.2% for AoD.

Diagnostic Ultrasound: On-Site Diagnosis of Type B Aortic Dissection During Cataract Surgery

We report a case of aortic dissection occurring during cataract surgery under local anesthesia, which was diagnosed on-site by point-of-care ultrasound. Intimal flaps were detected in the abdominal aorta, whereas the parasternal view showed no abnormalities in the aortic root or left ventricular function. According to these ultrasound findings, a Stanford type B aortic dissection was more likely than a type A aortic dissection, and imminent death was unlikely. Therefore, we decided to resume and complete the surgery. Subsequent computed tomography (CT) confirmed the point-of-care diagnosis. The patient was transferred to a tertiary hospital for medical treatment.

Comparison between transthoracic echocardiography and transoesophageal echocardiography in the diagnosis of acute aortic dissection from an emergency perspective. A systematic review and meta-analysis

Background

Acute aortic dissection (AAD) is a life-threatening medical condition with high early fatality. Therefore, a prompt and precise diagnosis, which can be achieved through invasive and non-invasive techniques is vital. Echocardiography, unlike MRI and CT, is accessible in emergency units and bedside-compatible. The recommended echocardiographic techniques for AAD are transthoracic and transoesophageal echocardiography (TTE and TOE). Therefore, our review compares their diagnostic roles in AAD.

Methods

Studies relevant to our topic were attained through a database search and manual scrutiny of references lists of articles obtained from the electronic databases. The Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) has been used for quality assessment. All quantitative analyses were performed using either STATA 16 or Comprehensive Meta-Analyst software.

Results

The search strategy yielded 1,798 articles, of which only 11 were eligible for inclusion. Our subgroup analysis showed that conventional TTE had a sensitivity and specificity of 85.35% and 84.51% for the diagnosis of Stanford type A AAD and was 45.89% sensitive and 87.05% specific for the diagnosis of type B AAD. However, the subgroup analysis shows that contrast-enhancement of TTE results in a sensitivity and specificity of 93.30% and 97.60% for diagnosis of type A AAD, and 83.60% and 94.50% for diagnosis of type B AAD, respectively. On the other hand, conventional TOE was 93.64% sensitive and 95.50% specific for the diagnosis of type A AAD, 99.80% sensitive and 99.87% specific for the diagnosis of type B AAD. Moreover, our analyses show that TTE has pooled false negative and positive rates of 28.6% and 18.6%, while TOE has shown false negative and positive rates of 2.4% and 4.3%, respectively.

Conclusion

TOE is the more favorable diagnostic tool for AAD diagnosis than TTE. However, it cannot be used as a stand-alone diagnostic tool since misdiagnosis cases are being reported. Contrast-enhanced TTE can also diagnose AAD since it provides similar results to conventional TOE.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Point-of-Care Ultrasound for the Diagnosis of Frequent Cardiovascular Diseases: A Review

Point-of-care ultrasound (POCUS) has emerged as an indispensable diagnostic tool in cardiology, particularly within the emergency department. This narrative synthesis provides a comprehensive exploration of POCUS applications in cardiovascular diseases, elucidating its multifaceted roles and addressing challenges. The review delves into the technical attributes of POCUS, emphasizing its non-invasive nature, radiation-free qualities, and suitability for non-radiologists. It navigates through educational strategies, stressing the importance of structured programs for the seamless integration of POCUS into clinical practice. Highlighting its efficacy, the synthesis discusses POCUS applications in various scenarios such as dyspnea, chest pain, cardiac arrest, aortic dissection, pericardial effusion, and pulmonary embolism. Beyond acute care, the review explores the role of POCUS in outpatient and inpatient settings, focusing on chronic and acute heart failure, valvular heart diseases, and more. Acknowledging operator-dependent challenges and the need for continuous education, the review underscores the transformative potential of POCUS across diverse healthcare settings. This narrative synthesis accentuates POCUS as a valuable and versatile diagnostic tool in cardiology, offering efficiency, safety, and cost-effectiveness. Despite challenges, POCUS stands out as a transformative addition to clinical practices, poised to enhance patient outcomes and reshape the landscape of cardiovascular diagnostics.

Clinical Usefulness of Echocardiographic Measurement of Proximal Aortic Diameter in Early Differentiation Between Type A Acute Aortic Dissection and ST-Segment-Elevation Myocardial Infarction

Background Contradictions between management modalities of type A acute aortic dissection (TAAAD) and ST-elevation-myocardial infarction (STEMI) may result in clinical catastrophe. Therefore, we aimed to explore which 2-dimensional echocardiography (2DE) findings are optimal for differentiating TAAAD from STEMI. Methods and Results This study included 340 patients with STEMI and 340 patients with TAAAD who underwent 2DE in the emergency department between 2012 and 2021. The proximal ascending aorta (PAA) diameter and other echocardiographic parameters were analyzed. PAA diameters were measured at 4 levels in the parasternal view: Valsalva, the sinotubular junction (STJ), the PAA at 1 cm above the STJ, and the PAA at 2 cm above the STJ. Receiver-operating characteristic curve analysis showed that Valsalva, STJ, PAA at 1 cm above the STJ, and PAA at 2 cm above the STJ were significant predictors of TAAAD (areas under the curve: 0.777, 0.924, 0.965, and 0.975, respectively; P<0.001) with the respective cutoff values of 39.4, 38.5, 39.8, and 41.2 mm. Multivariable analysis suggested that all 2DE parameters were significant predictors of TAAAD. Among the 2DE parameters examined, the incorporation of PAA at 2 cm above the STJ to clinical indicators exhibited the most significant diagnostic capability (C-statistics, 0.97; net reclassification improvement, 1.81; integrated discrimination improvement, 0.61). When only TAAAD with coronary malperfusion and STEMI were analyzed, the diagnostic utility of PAA at 1 cm above the STJ was evident (C-statistics, 0.99; net reclassification improvement, 1.79; integrated discrimination improvement, 0.67), with PAA at 2 cm above the STJ ranking second in diagnostic significance (C-statistics, 0.99; net reclassification improvement, 1.12; integrated discrimination improvement, 0.66). Conclusions PAA measurements were the most beneficial for diagnosing TAAAD in all 2DE findings and TAAAD from STEMI.

Abdominal ultrasound and VExUS score in critical care

The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41-91% and 94-100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50-100% and 93-100%, respectively; for >45 mm ranges were 64-65% and 95-99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.

Diagnostic accuracy of transthoracic echocardiography for the identification of proximal aortic dissection: a systematic review and meta-analysis

This systematic review and meta-analysis evaluated the performance of transthoracic echocardiography (TTE) for diagnosis of proximal aortic dissections based on the identification of specific sonographic features. A systematic literature search of major databases was conducted on human studies investigating the diagnostic accuracy of TTE for proximal aortic dissection. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of studies was evaluated using Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were gathered for the following sonographic findings: intimal flap, tear, or intramural hematoma; enlargement of aortic root or widening of aortic walls; aortic valve regurgitation; or pericardial effusion. Sensitivity, specificity, diagnostic odds ratio, number needed to diagnose values, and likelihood ratios were determined. Fourteen studies were included in our final analysis. More than half of the included studies demonstrated low risk of bias. The identification of intimal flap, tear, or intramural hematoma was shown to have an exceptional ability as a diagnostic tool to rule in proximal aortic dissections. TTE should be considered during the initial evaluation of patients presenting to the emergency department with suspected proximal aortic dissection. Positive sonographic findings on TTE may aid in rapid assessment, coordination of care, and treatment of individuals awaiting advanced imaging.

Routine Use of a Pocket-Sized Handheld Echoscopic Device Plus a Biomarker by Emergency Medicine Residents with an Early Screening Algorithm for Suspected Type A Acute Aortic Syndrome

(1) Background: The early screening strategy for type A acute aortic syndrome (A-AAS) patients has always been challenging. (2) Methods: From September 2020-31 March 2022, 179 consecutive patients with suspected A-AAS were retrospectively reviewed. We assessed the diagnostic value of the use of handheld echocardiographic devices (PHHEs) by emergency medicine (EM) residents either alone or in combination with serum acidic calponin in this patient group. (3) Results: The direct sign of PHHE had a specificity (SP) of 97.7%. The sign of ascending aortic dilatation showed SE = 77.6%, SP = 68.5%, PPV = 48.1% and NPV = 89%. SE, SP, PPV and NPV of a positive PHHE direct sign were 55.6%, 100%, 100% and 71.4% in 19 hypotension/shock patients with suspected A-AAS, respectively. The area under curve (AUC) of acidic calponin combined with an ascending aorta diameter >40 mm was 0.927, with an SE and SP of 83.7% and 89.2%, respectively. These two combined indicators significantly improved the diagnostic efficiency of A-AAS compared with either of them alone (p = 0.017; standard error 0.016, Z value 2.39; p = 0.001, standard error 0.028, Z value 3.29). (4) Conclusion: EM resident-performed PHHE was highly indicative of A-AAS in patients presenting with shock or hypotension. An ascending aorta diameter > 40 mm combined with acidic calponin demonstrated acceptable diagnostic accuracy as a rapid first-line triage tool to identify patients with suspected A-AAS.

Acute aortic syndromes: An internist's guide to the galaxy

Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.

Diagnostic performance of transthoracic echocardiography in screening acute type A aortic dissection from ST-segment elevated myocardial infarction

BACKGROUND

When patients with type A acute aortic dissection (TAAAD) present with changes to their ST-segment, diagnostic and treatment delays increase significantly. The performance of transthoracic echocardiography (TTE) screening of TAAAD in patients with ST-segment elevated myocardial infarction (STEMI) is yet to be validated.

METHODS

The diagnostic performance of TTE alone and combined with the aortic dissection risk score (ADRS) in TAAAD was evaluated. In this retrospective study (ChiCTR, No. 2000031291), TTE was reviewed to detect direct/indirect signs of TAAAD. The ADRS of each patient was calculated according to guidelines. Case adjudication was based on advanced imaging and surgery.

RESULTS

Among a total of 442 patients, TAAAD was diagnosed in 146 (33.0%). The presence of direct TTE signs had a sensitivity of 43.0% [95% confidence interval (CI): 35.0% to 52.0%] and specificity of 97.0% (95% CI: 95.0% to 99.0%), and the presence of any TTE sign had a sensitivity of 97.0% (95% CI: 93.0% to 99.0%) and specificity of 78.0% (95% CI: 73.0% to 82.0%) for TAAAD. The additive value of TTE was most evident in patients with low clinical probability for TAAAD (ADRS ≤1). The presence of ADRS ≤1 plus an absence of direct TTE signs for TAAAD rule-out had a sensitivity of 98.4% (95% CI: 96.1% to 99.6%).

CONCLUSIONS

The use of TTE adds value in the screening of TAAAD in STEMI patients. In patients with low clinical probability for TAAAD, direct TTE signs can be used to rapidly identify those who require advanced imaging.

Point-of-Care Abdominal Ultrasonography (POCUS) on the Way to the Right and Rapid Diagnosis

Point-of-Care ultrasound (POCUS) is based on target ultrasound that is performed wherever a patient is being treated, and by a non-radiologist directly involved in the patient’s care. It is used either for quick diagnosis or procedural guidance. Abdominal pain is one of the most common complaints in emergency departments, and POCUS can help in the differentiation of patients who need additional diagnostic tests or hospital treatment, which eventually reduces the overall costs of health care. POCUS has high sensitivity and specificity in abdominal pathology, it can be helpful in the evaluation of biliary, intestinal, and urinary tract, and it is especially used in trauma. Additionally, the gold standard for abdominal aortic aneurysm detection, follow up and screening is precisely this diagnostic procedure. Unfortunately, the quality of ultrasound examination can be affected by the experience of the physician performing it and the patient’s body weight. There is no doubt that POCUS is being increasingly recognized, but all motivated physicians should be provided with dedicated tutors and enough time for learning. This would certainly help to implement this diagnostic method as a routine in emergency and critical care departments, and significantly shorten the time until definitive diagnosis.

Shock after Mechanical Thrombectomy for Acute Ischemic Stroke: A Point-of-Care Ultrasound Diagnosis

•

POCUS can help identify etiology of acute ischemic stroke and expedite management.

•

POCUS is a useful initial screening modality for type A aortic dissection.

•

Type A aortic dissection extending to the carotids is an important cause of stroke.

•

POCUS is valuable to diagnose the etiology of shock in critically ill patients.

Atypical Presentation of Aortic Dissection in a Young Female and the Utility of Point-of-Care Ultrasound in Identifying Aortic Dissection in the Emergency Department

In the absence of prompt diagnosis and treatment, aortic dissection is an extremely dangerous and often fatal medical condition, of which acute coronary syndrome, stroke, limb ischemia, pulmonary embolism, and acute mesenteric ischemia are all possible manifestations. Neurological manifestations of aortic dissection are often missed at presentation. We report a case of a 23-year-old female without any prior characteristics of connective tissue disorder presenting to the emergency department with headache and right upper limb weakness and the utility of bedside point-of-care ultrasound (POCUS) for diagnosing aortic dissection.

Echocardiography in the diagnosis of Shone’s complex and analysis of the causes for missed diagnosis and misdiagnosis

BACKGROUND

Shone’s complex is a rare syndrome characterized by congenital left heart defects that can differ among the patients.

AIM

To use echocardiography in the diagnosis of Shone’s complex and analyze the causes of missed diagnosis and misdiagnosis.

METHODS

This was a retrospective study of patients who underwent echocardiography and repair surgery from February 14, 2008, to November 22, 2019. The patients were followed once a year at the outpatient clinic after surgery.

RESULTS

Sixty-six patients were included. The patients were 2.7 (0.8-5.6) years of age, and 54.5% were male. Ten (15.2%) had a history of heart surgery. The most common heart defect was the Annulo-Leaflet mitral ring (ALMR) (50/66, 75.8%), followed by coarctation of the aorta (CoA) (43/66, 65.2%). The patients had a variety of combinations of defects. Only two (3.0%) patients had all four defects. None of the patients had a family history of congenital heart disease. The preoperative echocardiographic findings were examined against the intraoperative findings. Echocardiography missed an ALMR in 31 patients (47.0%), a parachute mitral valve (PMV) in one patient (1.5%), subaortic stenosis in one patient (1.5%), and CoA in two patients (3.0%).

CONCLUSION

Echocardiography is an effective method to diagnose the Shone’s complex. Due to this disease’s complexity and interindividual variability, Improving the understanding of the disease can reduce misdiagnosis and missed diagnosis.

Stanford - A Aortic Dissection Presenting as a Triple Mimic and Role of Point of Care Ultrasound in Deciphering It

Aortic dissection (AD) is a great imitator, and its diagnosis is quite challenging due to its varied presentations and unreliable clinical findings. Based on the literature search we found, this is the first case report of Stanford-A/DeBakey Type 1 AD reported as a triple mimic, namely stroke, acute limb ischemia, and pericarditis. Here, we describe the case of a 46-year-old male who presented to our emergency department with features suggestive of acute pericarditis, cerebrovascular accident, acute limb ischemia, which could have been attributed to athero-thrombo-embolic disease and AD could have been possibly missed. However, point-of-care ultrasound helped us in the diagnosis of this highly lethal condition.

The Impact of Focused Cardiac Ultrasound Performed by Pediatric Intensivists: A Prospective Study

OBJECTIVES

Focused cardiac ultrasound is an echocardiographic method used by medical intensivists for fast and reliable hemodynamic assessment. Prospective studies and guidelines have defined its role in adult critical care. Data regarding its use in pediatric critical care are scarce. This is the first prospective study that aims to evaluate its impact in this setting.

METHODS

This is a single-center prospective study performed in a tertiary referral hospital pediatric intensive care unit (PICU). For a period of 6 months, when performing an echocardiogram, pediatric intensivists filled out a questionnaire that included the patient's clinical data and indication for the examination. The intensivists had to record both the clinical impression regarding that indication and therapeutic plan before and after the echocardiogram. All the patients with an echocardiogram performed by the pediatric intensive care unit medical staff were included.

RESULTS

There were 80 echocardiograms performed on 35 patients during the study period. The most common patient diagnostic groups were respiratory infections (38%, n = 30) and septic shock (21%, n = 17). The main indication for the examination was assessment of intravascular volume status and left ventricular systolic function. After the echocardiogram, the clinical impression was maintained in 49% (n = 39) and changed in 44% (n = 35). There were new findings unrelated to the initial evaluation in 7% (n = 6). The planned treatment was maintained in 55% (n = 44) and changed in 45% (n = 36).

CONCLUSIONS

The echocardiogram changed the clinical impression and therapeutic plan in almost half of the patients. These data show the value of focused cardiac ultrasound as a diagnostic and hemodynamic monitoring tool in pediatric intensive care and emphasize the importance of a rigorous training program.

Ultrasound Imaging of the Abdominal Aorta: A Comprehensive Review

Ultrasound is the imaging modality of choice for the initial evaluation of disorders that involve the abdominal aorta (AA). The diagnostic value of ultrasound resides in its ability to allow assessment of the anatomy and structure of the AA using two- dimensional, three-dimensional, and contrast-enhanced imaging. Moreover, ultrasound permits evaluation of the physiologic and hemodynamic consequences of abnormalities through Doppler interrogation of blood flow, thus enabling the identification and quantification of disorders within the AA and beyond its boundaries. The approach to ultrasound imaging of the AA varies, depending on the purpose of the study and whether it is performed in a radiology or vascular laboratory or in an echocardiography laboratory. The aim of this review is to demonstrate the usefulness of ultrasound imaging for the detection and evaluation of disorders that involve the AA, detail the abnormalities that are detected or further assessed, and outline its value for echocardiographers, sonographers, and radiologists.

Indirect signs of aortic dissection on POC-TTE despite an ADD-RS of 0 and D-dimer < 500 ng/mL: A case report

Aortic dissection (AD) is a "can't miss" diagnosis for emergency physicians. An algorithm combining the Aortic Dissection Detection Risk Score (ADD-RS) with D-dimer has been proposed as a high-sensitivity clinical decision tool for AD that can determine the need for advanced imaging. Here we present a case of a 48-year-old male who presented to the emergency department (ED) with chest pain and dyspnea. He had an ADD-RS score of 0 and negative D-dimer, which placed him in the low-risk category not requiring further advanced imaging. Despite this, he was found to have a pericardial effusion and dilated aortic root on point-of-care transthoracic echocardiogram (POC-TTE). These findings increased suspicion for AD and prompted the emergency physician to order a computed tomography angiography (CTA), revealing a thoracic AD. The patient successfully underwent surgical repair. This case demonstrates that the ADD-RS + D-dimer algorithm would have erroneously ruled out AD, without the inclusion of indirect findings of AD from the POC-TTE. This highlights the value of using POC-TTE as an adjunct to the ADD-RS + D-dimer algorithm in the diagnostic evaluation of AD and how giving more weight to indirect signs of AD on POC-TTE could potentially increase the sensitivity of the combined ADD-RS + D-dimer + POC-TTE algorithm.

Acute aortic dissection with highly compressed true lumen: unanticipated pitfall of point-of-care ultrasonography

A 46-year-old man presented with sudden onset of chest pain. He was in cardiogenic shock at arrival. Based on the results of ECG and echocardiogram, he was diagnosed with ST-segment elevation myocardial infarction. Point-of-care ultrasonography (POCUS) did not reveal acute aortic dissection (AAD). During an emergency coronary angiography, aortic dissection was detected and computed tomographic angiography (CTA) revealed Stanford type A AAD with a highly compressed true lumen. Because of this form of aortic dissection, the enlarged false lumen could be potentially misidentified as a normal aorta in POCUS. Although POCUS is useful when AAD is suspected, we should not overestimate its findings and lower the threshold for CTA.

Bedside Cardiac Pocus in Emergency Setting: A Practice Review

BACKGROUND

In the last years, ultrasound technology has entered clinical practice as a tank and today, it has also allowed no-cardiologists to extend their medical examination without needing to call the consultant and having a good profile of diagnostic accuracy. The ultrasound bedside does not replace the consultant, but it allows not to perform inappropriate consultations with more savings for hospitals.

OBJECTIVE

The aim was to review the recently published literature to inform the clinician about the most up to date management of use bedside echography in the emergency setting. In this short review, we focused on two types of syndromes, no traumatic- hypotension and dyspnea, common to the three holistic disciplines of medicine, showing the main and basic questions and answers that ultrasound can give us for rapid identification of the problems.

METHODS

We conducted a systematic review using Pubmed/Medline, Ovid/Willey and Cochrane Library, combining key terms such as "cardiac ultrasound, "cardiac diseases", "emergency medicine", "pocus", "dyspnea", " hypotension". We selected the most relevant clinical trials and review articles (excluding case reports) published in the last 19 years and in our opinion, 59 publications appeared to be the best choice according to the PRISMA statement. In additional papers identified from individual article reference lists were also included.

CONCLUSION

Recent studies have shown a promise in establishing best practices for evaluation of heart, lung abdomen and deep vessels At the moment, bedside US is widely used in an integrated ultrasound vision just like the holistic view have internal medicine, intensive care and emergency medicine and many medical schools in Europe and the USA are inserting ultrasonography into the core curriculum, but we still have to find a standard method for the training program for minimum competence acquisition.

Diagnosis and management of acute aortic syndromes in the emergency department

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

[Lumbar Back Pain and Impaired Vision - an Alarming Differential Diagnosis]

Lumbar Back Pain and Impaired Vision - an Alarming Differential Diagnosis Abstract. Aortic dissection is much less common than other causes of back pain, yet associated with a high mortality. Despite major advances in noninvasive imaging, the correct diagnosis is made in less than half of the cases. End-organ malperfusion can lead to a broad spectrum of symptoms making diagnosis difficult. This clinical case illustrates the importance of a careful history and thorough clinical examination, as well as noninvasive imaging without delay in order to improve the prognosis and chances of survival.

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

AIMS

The diagnosis of acute aortic syndromes (AASs) is challenging and requires integrated strategies. Transthoracic focused cardiac ultrasound (FoCUS) is endorsed by guidelines as a first-line/triage tool allowing rapid bedside assessment of the aorta. However, the performance of FoCUS in the European Society of Cardiology-recommended workup of AASs awaits validation.

METHODS AND RESULTS

This was a prespecified subanalysis of the ADvISED multicentre prospective study. Patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score (ADD-RS). Case adjudication was based on advanced imaging, surgery, autopsy, or 14-day follow-up. An AAS was diagnosed in 146 (17.4%) of 839 patients. Presence of direct FoCUS signs had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37-53.6%] and 97.4% (95% CI 95.9-98.4%), while presence of any FoCUS sign had a sensitivity and specificity of 89% (95% CI 82.8-93.6%) and 74.5% (95% CI 71-77.7%) for AAS. The additive value of FoCUS was most evident within low clinical probability (ADD-RS ≤1). Herein, direct FoCUS signs were identified in 40 (4.8%) patients (P < 0.001), including 29 with AAS. ADD-RS ≤1 plus negative FoCUS for AAS rule-out had a sensitivity of 93.8% (95% CI 88.6-97.1%) and a failure rate of 1.9% (95% CI 0.9-3.6%). Addition of negative D-dimer led to a failure rate of 0% (95% CI 0-1.2%).

CONCLUSION

FoCUS has additive value in the workup of AASs. Direct FoCUS signs can rapidly identify patients requiring advanced imaging despite low clinical probability. In integrated bundles, negative FoCUS is useful for rule-out of AASs.

Postpartum aortic dissection diagnosed by point-of-care ultrasound in the emergency department: A case study

Aortic dissection is a rare but clinically significant cause of chest pain in the emergency department (ED). While classic risk factors include advanced age, male sex, and tobacco use, pregnancy is also an independent and easily overlooked risk factor. Aortic dissection carries both high maternal and fetal morbidity and mortality. Point-of-care ultrasound is increasingly employed in the ED and has been shown to be useful in the evaluation of abdominal aortic pathologies. We present a case in which abdominal aortic ultrasound was utilized in the diagnosis of an acute Stanford type B aortic dissection in a recently postpartum patient.

Type A aortic dissection mimicking saddle pulmonary embolism on CT imaging

Type A aortic dissection is an uncommon cause of chest pain that carries a high morbidity and mortality rate. A previous history of hypertension and coronary artery bypass grating (CABG) are recognized risk factors for Type A aortic dissection. We present a case of an elderly man who presents with acute onset chest pain and was found to have an acute ruptured Type A aortic dissection that has a "saddle pulmonary embolism"-like appearance on computed tomography (CT) imaging. We also describe the clinical, laboratory, and radiological workup done leading up to the diagnosis of Type A aortic dissection in the emergency setting.

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

Early Screening for Aortic Dissection With Point-of-Care Ultrasound by Emergency Physicians: A Prospective Pilot Study

OBJECTIVES

To investigate the effect of point-of-care ultrasound (POCUS) use by emergency physician (EPs) on the diagnosis, treatment, and safety of POCUS in patients with aortic dissection (AD) in emergency settings.

METHODS

Patients presenting to the emergency department of West China Hospital of Sichuan University with suspected AD from July 1, 2016, to December 31, 2016 were divided into a control group and an ultrasound (US) group. The control group was evaluated by routine procedures for triage, diagnosis, and treatment. In addition, an EP POCUS examination was performed in the US group. The patients in the US group were furtherly divided into subgroup A and subgroup B according to the Stanford type of AD. The sensitivity and specificity of EP POCUS compared to computed tomographic angiography (CTA) were compared. The door-to-CTA examination time, door-to-diagnosis time, door-to-targeted treatment time, and outcome were compared between the groups.

RESULTS

A total of 127 patients were enrolled: 72 in the US group and 55 in the control group. In the US group, compared with CTA, the sensitivity of EP POCUS was 86.4%, and the specificity was 100.0%. The door-to-diagnosis times were 10.5 minutes in the US group and 79.0 minutes in the control group (P < .05). The door-to-CTA examination time and the door-to-targeted-treatment time had no differences between the US and control groups (P > .05). The in-hospital mortality and mortality within 3 months after discharge were 4.2% and 25.0% in the US group and 9.1% and 20.8% in the control group (P > .05).

CONCLUSIONS

Compared with CTA, EP POCUS in patients suspected of having AD is highly sensitive and specific and has shown no adverse effect on the treatment start-up time, in-hospital mortality, and mortality within 3 months after discharge.

Iatrogenic Aortic Dissection Presenting With Leg Pain Diagnosed With Point-of-care Ultrasound

Iatrogenic aortic dissection (IAD) status-post-cardiac catheterization is a rare complication often isolated to the proximal aorta. This is a case of IAD isolated to the distal aorta in a 41-year-old female who presented to the emergency department with right leg pain after undergoing three cardiac catheterizations. The diagnosis of IAD was made upon discovery of an intimal flap in the distal aorta and femoral artery while performing a point-of-care ultrasound to evaluate for deep vein thrombosis.

Detection of Type B Aortic Dissection in the Emergency Department with Point-of-Care Ultrasound

Aortic dissection (AD) is a rare, time-sensitive, and potentially fatal condition that can present with subtle signs requiring timely diagnosis and intervention. Although definitive diagnosis is most accurately made through computed tomography angiography, this can be a time-consuming study and the patient may be unstable, thus preventing the study’s completion. Chest radiography (CXR) signs of AD are classically taught yet have poor diagnostic reliability. Point-of-care ultrasound (POCUS) is increasingly used by emergency physicians for the rapid diagnosis of emergent conditions, with multiple case reports illustrating the sonographic signs of AD. We present a case of Stanford type B AD diagnosed by POCUS in the emergency department in a patient with vague symptoms, normal CXR, and without aorta dilation. A subsequent review of CXR versus sonographic signs of AD is described.

Discriminatory Value of the Ascending Aorta Diameter in Suspected Acute Type A Aortic Dissection

OBJECTIVE

The objective was to determine if ascending aorta (AscAo) diameters measured by noncontrast computed tomography (CT) allow for meaningful discrimination between patients with and without type A aortic dissection (TAAD), ideally with 100% sensitivity.

METHODS

This study was a retrospective analysis of cases of TAAD, as well as controls, undergoing evaluation for TAAD with CT aortography, presenting to 21 emergency departments within an integrated health system between 2007 and 2015. AscAo diameters were determined using axial noncontrast CT images at the level of the right main pulmonary artery by two readers. AscAo diameters were additionally normalized for age, sex, and body surface area (assessed by a Z-score, which is the number of standard deviations between the observed and expected AscAo diameters). Overall model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Comparative discrimination was assessed using both the change in AUC (∆AUC) and the continuous net reclassification index (NRI).

RESULTS

A total of 230 cases of TAAD and 325 controls were included in the study. The median ages for cases and controls were 65 and 62 years, and the median AscAo diameters were 50 and 35 mm, respectively. The raw and normalized AscAo diameters demonstrated similarly excellent discrimination (AUCs of 0.96 vs. 0.97, respectively; ∆AUC = 0.01, p = 0.09) and an NRI of 0.30 (95% confidence interval [CI] = 0.13-0.47), both indicating small incremental improvements in classification with the use of the normalized AscAo measures. A raw AscAo diameter of 34 mm and a normalized Z-score of 1.84 both yielded 100% sensitivity for TAAD, with respective specificities of 35% (95% CI = 29.6%-40.2%) and 67% (95% CI = 61.7%-72.2%).

CONCLUSIONS

Nearly all patients with TAAD appear to have enlarged AscAo diameters as measured by noncontrast CT, whereas most patients with suspected but absent TAAD have relatively normal AscAo diameters. Both raw and normalized AscAo measures provided relatively comparable discriminatory value. If validated, these data may be useful in adjudicating risk among patients with suspected TAAD in whom a criterion standard test is unavailable, nondiagnostic, or contraindicated.

Point-of-care Ultrasound Diagnosis of an Atypical Acute Aortic Dissection

Aortic dissections have a vast array of clinical presentations that rarely follow traditional teachings. Dissections are rapidly fatal conditions requiring immediate diagnosis and treatment to reduce morbidity and mortality. We present a case of an acute aortic dissection presenting as abrupt onset, atraumatic leg pain with absent distal extremity pulses. The prompt use of point-of-care ultrasound detected an intimal flap within the abdominal aorta allowing immediate surgical consultation and intervention.

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

Urgent Detection of Acute Type A Aortic Dissection in Hyperacute Ischemic Stroke or Transient Ischemic Attack

BACKGROUND AND PURPOSE

Urgent diagnosis of acute Stanford type A aortic dissection (AAD) in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) is sometimes challenging. We assessed predictive values for markers of AAD in patients with AIS or TIA.

METHODS

Consecutive patients with AIS or TIA with AAD who presented to our emergency room within 4.5 hours of symptom onset between 2007 and 2014 were compared with patients without AAD seen between 2012 and 2014.

RESULTS

Data were obtained for 24 patients with AIS or TIA with AAD (15 women; mean age, 75 ± 12 years) and 812 patients without AAD (305 women; mean age, 73 ± 12 years). Compared with patients without AAD, patients with AAD displayed significantly higher systolic blood pressure (SBP) laterality (30 ± 20 mm Hg versus 12 ± 11 mm Hg), initial D-dimer concentration (median 38.1 µg/mL versus 1.3 µg/mL), and mediastinal width-to-chest width (M/C) ratio on x-ray (.35 ± .05 versus .29 ± .05), and more frequently showed common carotid artery (CCA) dissection on carotid ultrasonography (84% versus 1%) and pericardial effusion on echocardiography (43% versus 0%). Sensitivity and specificity to identify AAD were 80% and 75% for SBP laterality 17 mm Hg or greater; 100% and 86% for D-dimer concentration 4.1 µg/mL or greater; 75% and 76% for M/C ratio .32 or greater; 84% and 99% for CCA dissection; and 43% and 100% for pericardial effusion, respectively.

CONCLUSIONS

High D-dimer level may provide the most reliable screening test for AAD in patients with AIS or TIA. CCA dissection on ultrasonography appears to represent the most disease-specific finding and shows acceptable sensitivity.

Values of aortic dissection detection risk score combined with ascending aorta diameter >40 mm for the early identification of type A acute aortic dissection

Background

Type A acute aortic dissection (A-AAD), involving the ascending aorta, is a life-threatening disease. To detect A-AAD early and rapidly in patients with acute chest pain, especially in patients with acute myocardial infarction (AMI) secondary to A-AAD, we investigated values of combined use of the risk score and the ascending aorta diameter >40 mm for the early identification of A-AAD.

Methods

Our study retrospectively encompassed 239 patients with acute chest pain on admission to our hospital between July 2010 and December 2016. The risk score was calculated according to the aortic dissection detection (ADD) risk score system, and the ascending aorta diameter was accurately obtained from the transthoracic echocardiography (TTE).

Results

A risk score ≥1 had an excellent sensitivity of 94.9% and a fair negative predictive value (NPV) of 77.8%, with a poor specificity of 8.7% and a positive predictive value (PPV) of 33.5% for the diagnosis of A-AAD. A risk score ≥2 had an excellent specificity of 91.3% and a fair NPV of 73.1%, whereas it had a lower sensitivity of 30.8% and a PPV of 63.2%. A risk score ≥1, combined with an ascending aorta diameter >40 mm, had a sensitivity, a specificity, a PPV, and an NPV of 84.6%, 87.6%, 76.7%, and 92.2% for the diagnosis of A-AAD, respectively. The combined use of a risk score ≥2 and an ascending aorta diameter >40 mm had an excellent specificity of 98.1% and a PPV of 86.4%, a fair NPV of 72.8%, and a poor sensitivity of 24.4% for the detection of A-AAD. Moreover, the omission diagnostic rate for A-AAD was significantly decreased from 33.3% to 7.4% using a risk score ≥1 combined with an ascending aorta diameter >40 mm in patients with AMI secondary to A-AAD.

Conclusions

The combined use of an ADD risk score ≥1 and an ascending aorta diameter >40 mm was highly indicative of A-AAD in patients presenting with acute chest pain, especially in patients with AMI secondary to A-AAD, which urgently needed computed tomography angiography (CTA) or magnetic resonance imaging (MRI) to confirm the diagnosis of A-AAD.