Diagnosis and management of acute aortic syndromes in the emergency department

Understanding the current acute aortic syndrome (AAS) pathways-The Collaborative Acute Aortic Syndrome Project (CAASP) protocol

BACKGROUND

Acute aortic syndrome (AAS) is an emergency associated with high peri-hospital mortality rates. Variable clinical presentation makes timely diagnosis challenging and such delays in diagnosis directly impact patient outcomes.

AIMS AND OBJECTIVES

The aims of the Collaborative Acute Aortic Syndrome Project (CAASP) are to characterise and evaluate the current AAS pathways of a cohort of hospitals in the UK, USA and New Zealand to determine if patient outcomes are influenced by the AAS pathway (time to hospital admission, diagnosis and management plan) and demographic, social, geographic and patient-specific factors (clinical presentation and comorbidities). The objectives are to describe different AAS pathways and time duration between hospital admission to diagnosis and management plan instigation, and to compare patient outcomes between pathways.

METHODS

The study is a multicentre, retrospective service evaluation project of adult patients diagnosed on imaging with AAS. It will be coordinated by the UK National Interventional Radiology Trainee Research (UNITE) network and Vascular and Endovascular Research Network (VERN) in conjunction with The Aortic Dissection Charitable Trust (TADCT). All AAS cases diagnosed on imaging between 1st January 2018 to 1st June 2021 will be included and followed-up for 6 months. Eligibility criteria include aortic dissection (AD) Type A, Type B, non A/B, penetrating aortic ulcer, and intramural haematoma. Exclusion criteria are non-AAS pathology, acute on chronic AAS, and age<18. This project will evaluate patient demographics, timing of presentation, patient symptoms, risk factors for AD, physical examination findings, timing to imaging and treatment, hospital stay, and mortality. Univariate and multivariate analysis will be used to identify predictors associated with prolonged time to diagnosis or treatment and mortality at 30 days.

High risk and low prevalence diseases: Acute limb ischemia

INTRODUCTION

Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization.

CONCLUSIONS

An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

[Benefits and drawbacks of CT scan as a triple rule-out exam in acute chest pain to exclude acute coronary syndrome, pulmonary embolism and aortic dissection]

Chest pain is one of the major causes for admission in the Emergency Room in most countries and one of the principal reasons for urgent consultation with a cardiologist or a general practitioner. After clinical examination and initial biological measurements, substantial patients require further explorations. CT scan allows the search for pulmonary embolism in the early stage of pulmonary arteries iodine contrast exploration. During the same exam at the systemic arterial phase, the search for aortic dissection or coronary artery disease is possible while exploring the later contrast in the aortic artery. This triple rule-out exam allows correct diagnosis in case of acute chest pain with suspected pulmonary embolism, aortic dissection and other acute aortic syndromes or acute coronary syndrome. But X-rays are substantially increased as well as iodine contrast agent quantity while exam quality is globally decreased. Artificial intelligence may play an important role in the development of this protocol.

Histopathological Gap in Aortic Diseases: A Prospective Analysis

Aortic dissection (AD) is a critical cardiovascular condition with the potential for devastating consequences. This study evaluated the histological changes in the aorta wall in patients with AD and aortic aneurysm (AA) who received surgical aortic replacement. Histopathological data showed that modifications of the media layer (p = 0.0197), myxomatous aspect (p = 0.0001), and subendothelial layer degeneration (p = 0.0107) were more frequently seen in AA versus AD samples. Patients with AA were approximately twice as likely to develop histological changes than those with AD (p = 0.0037). Patients with moderate or severe medial degeneration had a higher chance of developing AD (p = 0.0001). Because the histopathological score proved to be a predictor of both in-hospital and overall mortality, its evaluation should become the standard of care in any patients who undergo aortic replacement. Individualized postoperative management might be influenced by the histopathological aspect of the aortic layer.

Clinical Presentation and Emergency Department Management Checkpoints of Acute Aortic Syndromes during the First Two Waves of the COVID-19 Pandemic

The COVID-19 pandemic has deeply affected the activity and patient flows of Emergency Departments (EDs), and concern for the worsening outcome of cardiovascular emergencies has been raised. However, the impact of COVID-19 on all subtypes of acute aortic syndromes (AASs) has not been evaluated so far. Cases of AASs managed in the ED of three hub hospitals in a large area of Northern Italy were retrospectively analyzed, comparing those registered during the pandemic (March 2020 to May 2021) with corresponding pre-COVID-19 periods. A total of 124 patients with AAS were managed during the COVID-19 period vs. 118 pre-COVID-19 (p = 0.70), despite a -34.6% change in ED visits. Posterior chest pain at presentation was the only clinical variable with a different prevalence (46.0% vs. 32.2%, p = 0.03). Surgery and endovascular treatment rates were unchanged. Time intervals influenced by patient transfer to the hub center were longer during the COVID-19 period and longest during high viral circulation periods. Ninety-day mortality was unchanged, with a higher mortality trend during the pandemic surges. In conclusion, ED presentation and care of AASs were marginally affected by COVID-19, but efforts are needed to preserve efficient patient transfer to specialized centers and prevent mortality, especially during pandemic peaks.

Comparisons of potential values of D-dimer and the neutrophil- to-lymphocyte ratio in patients with suspected acute aortic syndrome

OBJECTIVES

This study aimed to investigate and compare the discriminative performance and clinical utility of D-dimer and the neutrophil-to-lymphocyte ratio (NLR) in the early differential diagnosis of acute aortic syndrome (AAS).

METHODS

The consecutive patients presenting to Tianjin Chest Hospital for suspected AAS were retrospectively investigated between June 2018 and December 2021. The baseline values of D-dimer and NLR were analyzed and compared in the study population. The discriminative ability of D-dimer and NLR was illustrated and compared using the area under the receiver operating characteristic (ROC) curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Clinical utility was evaluated by means of decision curve analysis (DCA).

RESULTS

In the study period, a total of 697 participants suspected of having AAS were enrolled and 323 had a final diagnosis of AAS. The baseline level of NLR as well as D-dimer was higher in patients with AAS. The use of NLR showed excellent overall diagnostic performance for AAS with a comparable AUC to that of D-dimer (0.845 vs. 0.822, P > 0.05). The reclassification analyses further confirmed that NLR had better discriminative properties for AAS with a significant NRI of 66.1% and IDI of 12.4% (P < 0.001). Moreover, NLR provided higher net benefit than D-dimer as shown by DCA. Similar results were observed in subgroup analyses according to the different classes of AAS.

CONCLUSIONS

NLR outperformed D-dimer with improved discriminative performance and superior clinical utility in identifying AAS. As a more readily available biomarker, NLR may be a reliable alternative to D-dimer for the screening of suspected AAS in clinical practice.

Pre-Test Probability Assessment and d-Dimer Based Evaluation in Patients with Previous Acute Aortic Syndrome

Background and Objectives. Acute aortic syndromes (AASs) are emergencies burdened by high morbidity and mortality. Guideline-recommended diagnostic workup is based on pre-test probability assessment (PPA) and d-dimer testing. However, the performance of PPA and d-dimer has never been studied in individuals with previous AAS (pAAS), which represent a challenging population. Materials and Methods. We analyzed a registry of patients with pAAS evaluated in two Emergency Departments (EDs) for suspected novel AAS (nAAS). Enrolment criteria were history of pAAS and the presence of truncal pain, syncope or perfusion deficit. All patients underwent advanced imaging. Clinical data were registered prospectively and PPA was performed by applying the aortic dissection detection (ADD) and an aorta simplified (AORTAs) score. Results. A total of 128 patients were enrolled, including 77 patients with previous Stanford type A aortic dissection and 45 patients with previous Stanford type B aortic dissection. The final diagnosis was nAAS in 40 (31%) patients. Clinical variables associated with nAAS were: aortic valve disease, thoracic aortic aneurysm, severe pain, sudden pain, ripping/tearing pain and hypotension/shock. ADD score ≥ 2 had a sensitivity of 65% and a specificity of 83% for nAAS; AORTAs score ≥ 2 had a sensitivity of 48% and a specificity of 88%. d-dimer (cutoff ≥ 500 ng/mL or age-adjusted cutoff) had a sensitivity of 97% and a specificity of 13%/14.7%, for diagnosis of nAAS. Patients that were candidates for guideline-compliant PPA/d-dimer integrated rule-out were: 5 (4.9%) with ADD ≤ 1/d-dimer and 8 (7.8%) with AORTAs ≤ 1/d-dimer < age-adjusted cutoff. None of them had a nAAS. Conclusions. Patients with pAAS evaluated in the ED for red-flag symptoms showed intermediate-to-high pre-test probability of nAAS. The ADD score had lower sensitivity and specificity than in unselected patients. d-dimer, alone and integrated with PPA, was highly sensitive for nAAS, but very unspecific. PPA/d-dimer integrated strategies are unlikely to significantly reduce the number of patients with pAAS undergoing advanced imaging.

Experience of the Postoperative Intensive Care Treatment of Stanford Type A Aortic Dissection

OBJECTIVE

To summarize the experience of the postoperative intensive care treatment of Stanford type A aortic dissection (STAAD) following Sun's procedure.

METHODS

A total of 124 patients with STAAD who underwent Sun's procedure from January 2014 to December 2021 at the General Hospital of Ningxia Medical University were retrospectively analyzed. All patients were admitted to the cardiac surgery intensive care unit (ICU) after surgery. According to the perioperative characteristics of the patients with STAAD, intensive care treatment was given to actively prevent the occurrence of postoperative complications.

RESULTS

In all the cases enrolled in this study, the causes of aortic dissection comprised hypertension (105 cases), trauma (six cases), Marfan's syndrome (six cases), and aorto-arteritis (seven cases). The history of past illnesses comprised hypertension (105 cases), coronary disease (25 cases), diabetes mellitus (16 cases), and chronic obstructive pulmonary disease (six cases). There were some preoperative complications, such as cardiac insufficiency, acute liver insufficiency, acute renal insufficiency, pleural effusion, pericardial effusion, pulmonary infection, lower limb ischemia, mesenteric arterial embolism, and digestive tract hemorrhage. The average cardiopulmonary bypass time was 186 ± 32.1 min, the aortic clamp time was 74 ± 12.8 min, the deep hypothermic circulatory arrest time was 21 ± 2.6 min, and the mechanical ventilation time was 34 ± 2.8 h. The average ICU and hospital residence times were 7 ± 1.6 days and 12 ± 3.6 days, respectively. Postoperative complications comprised hypoxemia (34 cases), pulmonary infections (22 cases), tracheostomy (four cases), cerebral hemorrhage (four cases), cerebral infarction (four cases), transient delirium (eight cases), secondary thoracotomies due to bleeding (two cases), alimentary tract hemorrhage (eight cases), and acute renal insufficiency (38 cases). There was no occurrence of hoarseness or chylothorax. There were 15 cases of death, and the total mortality rate was 12.1%. In four cases, the cause of death was one postoperative complication (3.2%), and in 11 cases, the cause of death was multiple postoperative complications (8.9%). The other patients were discharged from the hospital with a good prognosis for full recovery.

CONCLUSION

Postoperative intensive care treatment was an important part of the successful surgical treatment of STAAD.

Short-term prone positioning for severe acute respiratory distress syndrome after cardiopulmonary bypass: A case report and literature review

BACKGROUND

Aortic dissection is a complex and dangerous cardiovascular disease, with many complications in the perioperative period, including severe acute respiratory distress syndrome (ARDS), which affects prognosis and increases mortality. Despite the effect of prone positioning (PP) in improving oxygenation in patients with severe ARDS, reports about PP early after cardiac surgery are few and such an option may be an issue in cardiac surgery patients because of the recent sternotomy.

CASE SUMMARY

A 40-year-old male patient diagnosed with acute type A aortic dissection on October 22, 2021 underwent ascending artery replacement plus total aortic arch replacement plus stent elephant trunk implantation under cardiopulmonary bypass. Unfortunately, he developed ARDS on postoperative day 1. Despite comprehensive treatment with aggressive pulmonary protective ventilation, fluid management with continuous renal replacement therapy, the condition continued to deteriorate and rapidly progressed to severe ARDS with a minimum oxygenation index of 51. We are ready to implement salvage therapy, including PP and extracorporeal membrane oxygenation (ECMO). Due to the large amount of pericardial mediastinal and thoracic drainage after thoracotomy, ECMO may result in massive postoperative bleeding. Prolonged prone ventilation is often inappropriate after thoracotomy. Therefore, we chose short-term PP for < 6 h. Finally, the oxygenation index greatly improved and the diffuse exudation in both lungs of the patient was significantly reduced with short-term prone positioning.

CONCLUSION

Intermittent short-term PP can improve early postoperative severe ARDS after acute aortic dissection.

Bib Sign in Proximal Descending Thoracic Aorta Rupture on CT Angiography: Presentation of a Paradigmatic Case

Thoracic aortic rupture may present with subtle clinical and CT-angiography findings. Recognition of the imaging features of early rupture is key for timely diagnosis and treatment. This report presents a new sign of incipient proximal thoracic aortic rupture on CT-angiography.

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.

Progress of CT aortic angiography combined with coronary artery in the evaluation of acute aortic syndrome

Acute aortic syndrome (AAS) is a group of cardiovascular diseases that seriously threaten human life and health. AAS patients are often complicated with coronary artery disease and other related diseases, which require rapid and clear clinical diagnosis to avoid serious adverse events. In recent years, with the progress of science and technology, a variety of computer tomography (CT) angiography techniques have been applied in the clinic, and the diagnosis rate of AAS with coronary heart disease (CAD) has greatly increased. At the same time, the development of surgical technology and endovascular repair technology has significantly reduced the mortality and complication rate of AAS surgery. In the clinical diagnosis of AAS and related diseases, CT aortic angiography (CTA) combined with coronary CTA is increasingly applied to identify related diseases. Here, the current research progress on the technique of aortic CTA combined with coronary CTA is reviewed.

Outpatient management of patients after surgical operations for acute aortic dissection of type A

Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.

Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review

BACKGROUND

Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.

CASE SUMMARY

A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.

CONCLUSION

Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.

Effect of Optimized Emergency Care on Treatment Rate and Prognosis of Elderly Patients with Acute Stroke in Emergency Department: A Systematic Review and Meta-Analysis

Objective

This research was to detect the treatment rate and prognosis of elderly patients with acute stroke in emergency department by the optimization of emergency care applying meta-analysis.

Methods

The online databases including PubMed, EMBASE, ScienceDirect, Cochrane Library, China knowledge Network Database (CNKI), China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM) were searched. The retrieval time limit was set from the establishment of the database to the present. The data were extracted independently by two investigators. The bias of per publication was assessed following Cochrane manual 5.1.0 standard. RevMan5.4 statistical software was used to analyze the collected data by meta.

Results

The 8 randomized controlled trials included in this meta-analysis all reported patients' baseline status. The meta-analysis of the rescue time of the study group and the control group (CH2 = 1507.80, df = 4, P ≤ 0.001, and I2 = 100%) showed that the emergency nursing with optimized emergency procedures can shorten the rescue of elderly acute stroke patients in the emergency department time. There are 6 literatures reporting the case fatality rate (Chi2 = 1.12, df = 5, P = 0.95 > 0.05, and I2 = 0%), and the death rate of the study group was not higher than that of the control group (Z = 4.4 and P < 0.0001). The use of optimized first aid can reduce mortality in elderly patients with acute stroke. Six articles on disability rate reported the heterogeneity of disability rate (CH2 = 2.88, df = 5, P = 0.72 > 0.05, and I2 = 0%), indicating that the disability rate in the study group was lower than that in the control group (Z = 3.91 and P < 0.0001), indicating that emergency nursing by optimizing emergency procedures can reduce the disability rate of elderly stroke patients in emergency department.

Conclusion

Optimizing the emergency care process can effectively improve the emergency rate and prognosis of elderly patients with acute stroke in emergency department; however, further research with higher methodological quality and longer intervention time are needed to verify later.

D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have?

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.

Th1, Th2, and Th17 cells are dysregulated, but only Th17 cells relate to C-reactive protein, D-dimer, and mortality risk in Stanford type A aortic dissection patients

BACKGROUND

T helper (Th) cells are closely involved in vascular inflammation, endothelial dysfunction, and atherogenesis, which are the hallmarks of aortic dissection (AD). This study aimed to evaluate the clinical value of Th1, Th2, and Th17 cell measurements in Stanford type A AD patients.

METHODS

Stanford type A AD patients (N=80) and non-AD patients with chest pain (N = 40) were recruited. Then, Th1, Th2, and Th17 cells in peripheral blood CD4⁺ T cells from all participants were detected by flow cytometry. The 30-day mortality of Stanford type A AD patients was recorded.

RESULTS

Th1 and Th17 cells were higher, while Th2 cells were lower in Stanford type A AD patients compared with non-AD patients (all p < 0.001). Meanwhile, Th1 cells (area under curve (AUC): 0.734, 95% confidence interval (CI): 0.640-0.828), Th2 cells (AUC: 0.841, 95% CI: 0.756-0.925), and Th17 cells (AUC: 0.898, 95% CI: 0.839-0.957) could distinguish Stanford type A patients from non-AD patients. Moreover, Th1 cells (p = 0.037) and Th17 cells (p = 0.001) were positively related to CRP, and Th17 cells (p = 0.039) were also positively associated with D-dimer in Stanford type A AD patients. Furthermore, Th17 cells were elevated in deaths compared with survivors (p = 0.001), also, it could estimate 30-day mortality risk in Stanford type A AD patients with an AUC of 0.741 (95% CI: 0.614-0.867), which was similar to the value of CRP (AUC: 0.771, 95% CI: 0.660-0.882), but lower than the value of D-dimer (AUC: 0.818, 95% CI: 0.722-0.913).

CONCLUSION

Th1, Th2, and Th17 cells are dysregulated, but only the Th17 cells relate to CRP, D-dimer, and 30-day mortality risk in Stanford type A AD patients.

Early Prediction Model of Acute Aortic Syndrome Mortality in Emergency Departments

Purpose

Acute aortic syndrome is a constellation of life-threatening medical conditions for which rapid assessment and targeted intervention are important for the prognosis of patients who are at high risk of in-hospital death. The current study aims to develop and externally validate an early prediction mortality model that can be used to identify high-risk patients with acute aortic syndrome in the emergency department.

Patients and Methods

This retrospective multi-center observational study enrolled 1088 patients with acute aortic syndrome admitted to the emergency departments of two hospitals in China between January 2017 and March 2021 for model development. A total of 210 patients with acute aortic syndrome admitted to the emergency departments of Peking University Third Hospital between January 2007 and December 2021 was enrolled for model validation. Demographics and clinical factors were collected at the time of emergency department admission. The predictive variables were determined by referring to the results of previous studies and the baseline analysis of this study. The study’s endpoint was in-hospital death. To assess internal validity, we used a fivefold cross-validation method. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC). A nomogram was developed based on the binary regression results.

Results

In the development cohort, 1088 patients with acute aortic syndromes were included, and 88 (8.1%) patients died during hospitalization. In the validation cohort, 210 patients were included, and 20 (9.5%) patients died during hospitalization. The final model included the following variables: digestive system symptoms (OR=2.25; P=0.024), any pulse deficit (OR=7.78; P<0.001), creatinine (µmol/L)(OR=1.00; P=0.018), lesion extension to iliac vessels (OR=4.49; P<0.001), pericardial effusion (OR=2.67; P=0.008), and Stanford type A (OR=10.46; P<0.001). The model’s AUC was 0.838 (95% CI 0.784–0.892) in the development cohort and 0.821 (95% CI 0.750–0.891) in the validation cohort, and the Hosmer–Lemeshow test showed p=0.597. The fivefold cross-validation demonstrated a mean accuracy of 0.94, a mean precision of 0.67, and a mean recall of 0.13.

Conclusion

This risk prediction tool uses simple variables to provide robust prediction of the risk of in-hospital death from acute aortic syndrome and validated well in an independent cohort. The tool can help emergency clinicians quickly identify high-risk acute aortic syndrome patients, although further studies are needed for verifying the prospective data and the results of our study.

Nitric Oxide Inhalation Therapy Attenuates Postoperative Hypoxemia in Obese Patients with Acute Type A Aortic Dissection

Objective

To investigate the differences between inhaled nitric oxide (iNO) treatment and conventional therapy in the treatment of postoperative hypoxemia in obese patients with acute type A aortic dissection (ATAAD).

Methods

ATAAD patients diagnosed and treated with emergency surgery in our hospital from June 2017 to December 2019 were retrospectively analyzed. Patients with postoperative hypoxemia were divided into the iNO group and control group. Propensity score matching was used to analyze clinical characteristics and results of the two groups.

Results

A total of 218 ATAAD patients with BMI ≥ 25 were treated with surgery. Among them, 115 patients developed refractory hypoxemia (64 in the control group and 51 in the iNO group). Patients in the iNO group had significantly shorter invasive mechanical ventilation time, intensive care unit (ICU) stay, and hospital stay. After 6 h of iNO treatment, the PaO2/FiO2 ratio in the iNO group increased significantly, and this ratio was higher than that in the control group at 6, 12, 24, 48, and 72 h after treatment.

Conclusion

Low-dose iNO could improve oxygenation and shorten mechanical ventilation and ICU stay in patients with hypoxemia after ATAAD surgery, but without significant side effects or increase in postoperative mortality or morbidity. These findings provide a basis for a randomized multicenter controlled trial to assess the efficacy of iNO in the treatment of hypoxemia after ATAAD surgery.

MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.

Standardized Nursing Approach to Acute Aortic Dissection Patient: A Practice Update

Background

Acute aortic dissection (AAD) is a rare condition but represents a time-sensitive disease for which a wrong and untimely identification in the triage phase could compromise the subsequent diagnostic, therapeutic path and patient's prognosis. The emergency nurse plays a crucial role in identifying and managing patients with possible AAD. The aim of this paper is to describe the emergency department nursing approach to critical patients with suspected hyperacute/acute AAD.

Purpose

It is crucial to examine the emergency departments nursing approach to patients with suspected AAD. It is fundamental to have a rapid and standardized approach related to life-saving procedures, practices, and management of critical patients during the triage phase, with the assessment of the most common presentation of clinical signs and symptoms and patient management during each step in the emergency department.

Conclusion

Early identification and diagnosis in ED allow prompt treatment that improves prognosis. The emergency nurse plays a crucial role in correctly identifying and managing patients with acute aortic dissection. High clinical suspicion from the triage stages, early diagnosis, monitoring, and initial clinical stabilization in the emergency department plays a key role while awaiting definitive treatment.

D-Dimer Tests in the Emergency Department: Current Insights

In the Emergency Medicine setting, D-dimer is currently employed in the diagnostic assessment of suspected venous thromboembolism and aortic syndrome. The nonspecific symptoms reported by patients, like chest pain, dyspnea or syncope, uncover a wide range of differential diagnosis, spanning from mild to life-threatening conditions. Therefore, we assumed the perspective of the Emergency Physician and, in this narrative review, we reported a brief presentation of the epidemiology of these symptoms and the characteristics of patients, in whom we could suspect the aforementioned pathologies. We also reported in which patients D-dimer gives useful information. In fact, when the probability of the disease is high, the D-dimer level is futile. On the contrary, given the low specificity of the test, when the probability of the disease is very low, a false-positive value of the D-dimer only increases the risk of overtesting. Patients with low to moderate probability really benefit from the D-dimer testing, in order to prevent the execution of expensive and potentially dangerous imaging tests. In the second part of the review, we focused on the prognostic value of the test in septic patients. The early prognostic stratification of septic patients remains a challenge for the Emergency Physician, in the absence of a definite biomarker or score to rely on. Therefore, we need several parameters for the early identification of patients at risk of an adverse prognosis and the D-dimer may play a role in this demanding task. SARS COVID-19 patients represent an emerging reality, where the role of the D-dimer for prognostic stratification could be relevant. In fact, in patients with severe forms of this disease, the D-dimer reaches very high values, which appear to parallel the course of respiratory failure. Whether the test may add useful information for the management of these patients remains to be determined.

Percutaneous pericardiocentesis for pericardial effusion: predictors of mortality and outcomes

Pericardial effusion can dangerously precipitate patient's hemodynamic stability and requires prompt intervention in case of tamponade. We investigated potential predictors of in-hospital mortality, a composite outcome of in-hospital mortality, pericardiocentesis-related complications, and the need for emergency cardiac surgery and all-cause mortality in patients undergoing percutaneous pericardiocentesis. This is an observational, retrospective, single-center study on patients undergoing percutaneous pericardiocentesis (2010-2019). We enrolled 81 consecutive patients. Median age was 71.4 years (interquartile range [IQR] 58.1-78.1 years) and 51 (63%) were male. Most of the pericardiocentesis were performed in an urgency setting (76.5%) for cardiac tamponade (77.8%). The most common etiology was idiopathic (33.3%) followed by neoplastic (22.2%). In-hospital mortality was 14.8% while mortality during follow-up (mean 17.1 months) was 44.4%. Only hemodynamic instability (i.e., cardiogenic shock, hypotension refractory to fluid challenge therapy and inotropes) was associated with in-hospital mortality at the univariate analysis (odds ratio [OR] 7.2; 95% confidence interval [CI] 1.76-29.4). Non-neoplastic/non-idiopathic etiology and hemodynamic instability were associated with the composite outcome of in-hospital mortality, need for emergency cardiac surgery, or pericardiocentesis-related complications (OR 5.75, 95% CI 1.65-20.01, and OR 5.81, 95% CI 2.11-15.97, respectively). Multivariate Cox regression analysis adjusted for possible confounding variables (age, coronary artery disease, and hemodynamic instability) showed that neoplastic etiology was independently associated with medium-term mortality (hazard ratio [HR] 4.05, 95% CI 1.45-11.36). In a real-world population treated with pericardiocentesis for pericardial effusion, in-hospital adverse outcomes and medium-term mortality are consistent, in particular for patients presenting with hemodynamic instability or neoplastic pericardial effusion.

CE: Hypertensive Emergencies: A Review

ABSTRACT

While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.

Nomogram to differentiate between aortic dissection and non-ST segment elevation acute coronary syndrome: a retrospective cohort study

Background

Aortic dissection (AD) and non-ST segment elevation acute coronary syndrome (ACS) are two of the most life-threatening diseases encountered in the emergency department (ED), but there are no rapid and reliable tools for differentiation. The purpose of this study is to develop and validate a nomogram that incorporates both the clinical characteristics and bedside laboratory tests available to differentiate between AD and non-ST segment elevation ACS (NSTE-ACS).

Methods

Between January 2016 and July 2018, patients with AD and NSTE-ACS were enrolled and divided into training and validation groups. The least absolute shrinkage and selection operator (LASSO) regression model was used to select the factors with significant value of predicting the diagnosis of AD. A nomogram was built on the basis of multivariable logistic regression analysis. Area under the curve (AUC) of receiver operating characteristic (ROC) curve and the calibration curve were used to assess the performance of the nomogram. Decision curve analysis was performed to assess the clinical utility of the nomogram.

Results

A final cohort of 263 patients (94 patients with AD and 169 patients with NSTE-ACS) were enrolled. Six variables were incorporated in the nomogram: pain severity, tearing pain, pulse asymmetry, electrocardiogram (ECG), D-dimer level and troponin I level. The AUC of the nomogram to predict the probability of AD was 0.919 (95% CI, 0.876-0.962) in the training group and 0.938 (95% CI, 0.888-0.989) in the validation group. The calibration curve demonstrated a good consistency between the actual clinical results and the predicted outcomes. The decision curve analysis indicated that the nomogram had higher overall net benefits in predicting AD in both the training group and the validation group.

Conclusions

We developed and validated a predictive nomogram that could be used as a tool to differentiate AD from NSTE-ACS rapidly and accurately.

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.