Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection

Diagnosing aortic dissection: A review of this elusive, lethal diagnosis

Aortic dissection (AD) remains a difficult diagnosis in the emergency setting. Despite its rare occurrence, it is a life-threatening pathology that, if missed, is typically fatal. Previous studies have documented minimal improvement in timely and accurate diagnoses despite the advancement of computed tomography. Previous literature has highlighted aortic dissections as a major cause of serious misdiagnosis-related harm. The aim of this article is to review the available literature on AD, discussing the diversity in presentations and the prevalence of historical and exam features to better aid in the diagnosis of AD. AD remains a difficult diagnosis, even with the widespread prevalence of computed tomography angiography usage. No single feature of the history or physical examination is enough to raise suspicion. The diagnosis should be strongly considered in any patient with chest pain that is severe and unexplained by other findings or testing. Those who do not present with acute pain are often complicated by neurologic deficits, hypotension, or syncope. These patients suffer from a change in mental status limiting their ability to participate in the history and physical examination and have a higher rate of complications and mortality. An educated understanding of the atypical presentations of aortic dissection helps the clinician to realistically rank it on the differential diagnosis, culminating in judicious use of definitive imaging.

Acute Coronary Syndrome and Acute Abdomen Suspected for Type B Aortic Dissection in an Elderly Woman

Being an uncommon and challenging disorder, acute aortic dissection (AAD) can have fatal outcomes in the event of missed diagnosis or treatment delay. AAD could easily be misdiagnosed, as symptoms usually mimic other common clinical syndromes showing up in Accident and Emergency (A&E), including acute coronary syndrome (ACS), pericarditis, pulmonary embolism, acute abdomen, musculoskeletal pain, as well as presenting as heart failure, stroke, syncope, and absent peripheral pulses. We present a case of a 77-year-old female who presented to the medical decision unit with acute-onset chest, back, and abdominal pain that occurred on standing for six hours She was thought initially to have acute coronary syndrome based on electrocardiography (ECG) changes, troponin, a normal chest X-ray, and no blood pressure discrepancies in upper extremities. Due to worsening abdominal pain and a previous history of a perforated diverticulum, contrast computed tomography (CT) of the abdomen was arranged and this showed acute type B aortic dissection. By the time the CT was performed, the patient had been in hospital for 16 hours, almost 22 hours from the onset of pain.

Rapid Diagnosis of Acute Type A Aortic Dissection Through Multimodality Imaging

•TAAD is a rare and potentially fatal disease. •Aortic dissections have a wide range of common risk factors. •This condition can mistakenly present similar to other acute coronary syndromes. •Clinicians need clinical expertise and proper multimodality imaging for diagnosis. •Misdiagnosis of this condition can be dangerous and fatal to patients.

Improvement of Early Outcomes in Type A Acute Aortic Syndrome After an Aorta Code Implementation

BACKGROUND

Reduction of variability through process reengineering can improve surgical results for patients with type A acute aortic syndrome. We compare short-term results before and after implementation of an Aorta Code for patients with type A acute aortic syndrome who underwent surgery.

METHODS

The Aorta Code was implemented in a 5-hospital healthcare network in 2019. This critical pathway was based on a simple diagnostic algorithm, ongoing training, immediate patient transfer, and treatment by an expert multidisciplinary team. We retrospectively compared all patients operated on in our center before (2005-2018) and after (January 2019 to February 2023) its implementation.

RESULTS

One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly.

CONCLUSIONS

An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased.

Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study

INTRODUCTION

Acute aortic syndrome (AAS) is a life-threatening aortic emergency. It describes three diagnoses: acute aortic dissection, acute intramural haematoma and penetrating atherosclerotic ulcer. Unfortunately, there are no accurate estimates of the miss rate for AAS, risk factors for missed diagnosis or its effect on outcomes.

METHODS

A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of AAS were identified between 2003 and 2018 using a validated algorithm based on ICD codes and death. Before multivariate modelling, all categorical variables were analysed for an association with missed AAS diagnosis using χ2 tests. These preliminary analyses were unadjusted for clustering or any covariates. Finally, we performed multilevel logistic regression analysis using a generalised linear mixed model approach to model the probability of a missed case occurring.

RESULTS

There were 1299 cases of AAS (age mean (SD) 68.03±14.70, woman 500 (38.5%), rural areas (n=111, 8.55%)) over the study period. Missed cases accounted for 163 (12.5%) of the cohort. Mortality (non-missed AAS 59.7% vs missed AAS 54.6%) and surgical intervention (non-missed AAS 31% vs missed AAS 30.7%) were similar in missed and non-missed cases. However, lower acuity (Canadian triage acuity scale >2 (OR 2.45 95% CI 1.71 to 3.52) (the scale is from 1 to 5, with 1 indicating high acuity) had a higher odds of being a missed case and non-ambulatory presentation (OR 0.47 95% CI 0.33 to 0.67) and presenting to a teaching (OR 0.60 95% CI 0.40 to 0.90)) or cardiac centre (OR 0.41 95% CI 0.27 to 0.62) were associated with a lower odds of being a missed case.

CONCLUSIONS

The high rate of misdiagnosis has remained stable for over a decade. Non-teaching and non-cardiac hospitals had a higher incidence of missed cases. Mortality and rates of surgery were not associated with a missed diagnosis of AAS. Educational interventions should be prioritised in non-teaching hospitals and non-cardiac centres.

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.

Optimized strategy to improve the outcomes of acute type A aortic dissection with malperfusion syndrome

BACKGROUND

The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution.

METHODS

Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (first stage) or an optimized strategy (second stage). In the second stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed, followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the first and second stages.

RESULTS

The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in the second stage vs 12.5% in the first stage; P < .01). In the second stage, the in-hospital mortality for MPS was decreased (10.2% vs 33.9%; P < .01). Moreover, the in-hospital mortality for MPS with symptom onset within 6 hours and beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in the second stage was comparable to that in patients without MPS (4.0% vs 2.4%; P > .05).

CONCLUSIONS

The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For patients with MPS symptom onset within 6 hours, immediate central repair is reasonable; for those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.

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.

Thoracic aortic dissection presenting with bilateral haemothoraces: a potentially missed diagnosis

Thoracic aortic dissection is a life-threatening diagnosis, which should not be missed. We present a case in which a patient who presented to the emergency department with chest pain was assessed and referred for admission for treatment of pneumonia, due to misinterpretation of a chest radiograph finding. The patient was re-reviewed and subsequently underwent further investigation, which confirmed aortic dissection. She underwent emergency thoracic endovascular aortic graft repair with stent graft insertion. This case demonstrates haemothorax as an uncommon complication of aortic dissection.

Evaluation of the Canadian Clinical Practice Guidelines Risk Prediction Tool for Acute Aortic Syndrome: The RIPP Score

Introduction

Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality rate. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making (RIPP score). The aim of this study is to validate the diagnostic accuracy of this tool and assess its performance in comparison to other risk prediction tools that have been developed.

Methods

This was a historical case-control study. Consecutive cases and controls were recruited from three academic emergency departments from 2002-2020. Cases were identified through an admission, discharge, or death certificated diagnosis of acute aortic syndrome. Controls were identified through presenting complaint of chest, abdominal, flank, back pain, and/or perfusion deficit. We compared the clinical decision tools' C statistic and used the DeLong method to test for the significance of these differences and report sensitivity and specificity with 95% confidence intervals.

Results

We collected data on 379 cases of acute aortic syndrome and 1340 potential eligible controls; 379 patients were randomly selected from the final population. The RIPP score had a sensitivity of 99.7% (98.54-99.99). This higher sensitivity resulted in a lower specificity (53%) compared to the other clinical decision aids (63-86%). The DeLong comparison of the C statistics found that the RIPP score had a higher C statistic than the ADDRS (-0.0423 (95% confidence interval -0.07-0.02); P < 0.0009) and the AORTAs score (-0.05 (-0.07 to -0.02); P = 0.0002), no difference compared to the Lovy decision tool (0.02 (95% CI -0.01-0.05 P < 0.25)) and decreased compared to the Von Kodolitsch decision tool (0.04 (95% CI 0.01-0.07 P < 0.008)).

Conclusion

The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. It has the potential to improve diagnosis of AAS in the emergency department.

Acute Chest Pain—Diagnostic Accuracy and Pre-Hospital Use of Anticoagulants and Platelet Aggregation Inhibitors

BACKGROUND

Acute chest pain (aCP) can be a symptom of life-threatening diseases such as acute coronary or aortic syndrome, but often has a non-cardiac cause. The recommendations regarding pre-hospital drug treatment of patients with aCP are ambiguous.

METHODS

A retrospective cohort study was conducted of 822 patients with aCP who were attended by emergency physicians. The cause of aCP was classified as follows: acute coronary syndrome without ST-segment elevation (NSTE-ACS), acute aortic syndrome, hypertensive crisis, cardiac arrhythmias, musculoskeletal, or other. The suspected and discharge diagnoses were compared, and the pre-hospital administration of acetylsalicylic acid (ASA) and unfractionated heparin (UFH) was analyzed. Furthermore, the parameters that improved diagnostic accuracy were investigated.

RESULTS

The positive predictive value of the diagnosis assigned by the emergency physician (EP diagnosis) was 39.7%. NSTEACS was the most commonly suspected cause of aCP (74.7%), but was confirmed after hospital admission in only 26.3% of patients. ASA was administered in 51%, UFH in 55%, and both substances in 46.4% of cases. A large proportion of patients received anticoagulants in the pre-hospital setting although the discharge diagnosis was not NSTE-ACS: ASA 62.9%, UFH 66.0%, both substances 56.5%.

CONCLUSION

ASA and UFH are often given to EP-accompanied patients with aCP despite the low accuracy of diagnosis in the pre-hospital setting. Pre-hospital measurement of high-sensitivity troponin T (hs Trop-T) might improve discrimination between NSTE-ACS and other causes of aCP. This is important, as the current guidelines contain no clear recommendations for prehospital drug treatment in NSTE-ACS.

The D-Dimer to Troponin Ratio Is a Novel Marker for the Differential Diagnosis of Thoracic Acute Aortic Syndrome from Non-ST Elevation Myocardial Infarction

BACKGROUND

Thoracic acute aortic syndrome (AAS) and non-ST elevation myocardial infarction (NSTEMI) have similar clinical presentations, making them difficult to differentiate. This study aimed to identify useful biomarkers for the differential diagnosis of thoracic AAS and NSTEMI.

METHODS

This was a retrospective observational study.

PARTICIPANTS

consecutive adult patients who visited the emergency department for acute chest pain between January 2015 and December 2021 diagnosed with thoracic AAS or NSTEMI. Clinical variables, including D-dimer (μg/mL) and high-sensitivity troponin T (ng/mL, hs-TnT) levels, were compared between the groups.

RESULTS

A total of 52 (30.1%) and 121 (69.9%) patients were enrolled in the thoracic AAS and NSTEMI groups, respectively. Logistic regression analysis revealed that the D-dimer to hs-TnT (D/T) ratio (odds ratio (OR), 1.038; 95% confidence interval (CI), 1.020-1.056; p < 0.001) and the thrombolysis in myocardial infarction (TIMI) score (OR, 0.184; 95% CI, 0.054-0.621; p = 0.006) were associated with thoracic AAS. The D/T ratio had an area under the receiver operating characteristic curve (AUC) of 0.973 (95% CI, 0.930-0.998), and the optimal cutoff value was 81.3 with 91.4% sensitivity and 96.2% specificity. The TIMI score had an AUC of 0.769 (95% CI, 0.644-0.812), and the optimal cutoff value was 1.5 with 96.7% sensitivity and 38.5% specificity.

CONCLUSION

the D/T ratio may be a simple and useful parameter for differentiating thoracic AAS from NSTEMI.

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.

Development and validation of nomogram models to discriminate between acute aortic syndromes and non-ST-elevation myocardial infarction during troponin-blind period

Background

Blood-test-based methods of distinguishing between acute aortic syndromes (AASs) and non-ST-elevation myocardial infarction (NSTEMI) during the troponin-blind period of <2-3 h of symptom onset have not been studied previously. We aimed to explore whether routine biomarkers might facilitate differential diagnosis.

Methods

Data were retrospectively collected from 178 patients with AASs and 460 patients with NSTEMI within 3 h of onset. Differential risk factors related to AASs were identified by univariate and multivariate logistic regression analyses for patients with onset <2 h and onset ≥2 h, respectively, in the cardiac troponin (cTn) cohort. Nomograms were established in the cTn cohort as a training set and validated in the high-sensitivity cTn cohort. To assess the utility of the models in clinical practice, decision curve analyses were performed.

Results

D-dimer, fibrinogen, and age were identified as differential risk factors for AASs with the onset of <2 h. D-dimer at an optimal cutoff level of 281 ng/mL for AASs had a sensitivity of 86.4% and a specificity of 91.3%. A nomogram was developed and validated with areas under the curve (AUC) of 0.934 (95% CI: 0.880-0.988) and 0.952 (95% CI: 0.874-1.000), respectively. D-dimer, neutrophil, bilirubin, and platelet were the differential risk factors for AASs with the onset of ≥2 h. D-dimer at an optimal cutoff level of 385 ng/mL has a sensitivity of 91.8% and a specificity of 91.3%. The AUC of the second nomogram in the training set and the validation set were 0.965 (95% CI: 0.942-0.988) and 0.974 (95% CI: 0.944-1.000), respectively.

Conclusion

Time-dependent quality of D-dimer should be considered for discriminating AASs from NSTEMI. Both nomogram models may have a clinical utility for evaluating the probability of AASs.

Predictive value of admission CO2 combining power combined with serum sodium for the prognosis in acute Stanford type A aortic dissection patients

Acute Stanford type A aortic dissection (ATAAD) with sudden onset and high mortality requiries a standard Bentall operation and a accurate prognosis in common, together with alteration of CO₂ combining power (CO₂CP) and serum sodium rase concern, hence, we evaluated the prognostic value of CO₂CP combined with serum sodium in ATAAD patients. This retrospective study included 183 patients who underwent Bentall operation for ATAAD from 2015 to 2021 in the Fourth Hospital of Hebei Medical University, subsequently followed grouping by the levels of CO₂CP and serum sodium. The study endpoint was 30-day all-cause mortality, and the prognostic value of CO₂CP combined with serum sodium levels in ATAAD patients were evaluated with multivariate logistic regression method. The postoperative incidence of in-hospital death and adverse events in patients with ATAAD were 18% and 25.7%, respectively. Combination of CO₂CP and serum sodium for predicting ATAAD death and adverse events presented a higher predictive value than each single indicator with ROC curve analysis (the AUC of CO₂CP combined with serum sodium was 0.786, 95% CI 0.706-0.869, P < 0.001), along with CO₂CP < 22.5 mmol/L + serum sodium > 138.5 mmol/L group had the worst prognostic. Multivariate regression analyse showed that CO₂CP < 22.5 mmol/L combined with serum sodium > 138.5 mmol/L preferably predicted the prognosis of ATAAD (OR =6.073, 95% CI 2.557-14.425, P < 0.001). Consistently, the cumulative 30-day survival after surgery in ATAAD patients with the low CO₂CP and high serum sodium simultaneously was the worst (log-rank P < 0.05). The combination of CO₂CP and serum sodium increases the predictive value of prognosis, which is conducive to risk stratification of patients with ATAAD.

Epidemiology, mortality and miss rate of acute aortic syndrome in Ontario, Canada: a population-based study

INTRODUCTION

Acute aortic syndrome (AAS) is a life-threatening emergency. It describes three distinct diagnoses: acute aortic dissection, acute intramural hematoma and penetrating atherosclerotic ulcer. There are currently no accurate estimates for incidence, mortality or misdiagnosis. Our objectives were to determine the incidence, mortality and miss rate of acute aortic syndrome in the emergency department (ED).

METHODS

A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of acute aortic syndrome were identified between 2003 and 2018 using a validated algorithm based on ICD-10 codes and death. Incidence (number of cases/population of Ontario), mortality, and miss rate were calculated. Miss rate was defined as when a patient was seen in the ED within 14 days prior to an acute aortic syndrome diagnosis with a presenting complaint consistent with acute aortic syndrome.

RESULTS

There were 1299 cases of acute aortic syndrome over the study period [age mean (SD) 68.03 ± 14.70; female (n = 500, 38.5%); rural areas (n = 111, 8.6%)]. The overall annual incidence for acute aortic syndrome was 0.61 per 100,000. One year mortality decreased from 47.4 to 29.1%. ED mortality was 14.9%. In the 14 days prior to diagnosis 12.5% of patients were seen in the ED with a presentation consistent with acute aortic syndrome.

CONCLUSIONS

Annual incidence of acute aortic syndrome was found to be lower than other population-based studies. Also, the burden of mortality is seen in the ED. Education initiatives should focus on the identification of acute aortic syndrome in the ED to address mortality and miss rate.

Type A Aortic Dissection With Intramural Hematoma: A Challenging Diagnosis

Intramural hematoma (IMH) is considered a part of acute aortic syndromes (AAS), a group of life-threatening aortic diseases with a similar presentation that appears to have different clinical manifestations and pathological and survival characteristics. AAS comprises three major entities, namely, aortic dissection (AD), IMH, and PAU. IMH-like classic AD is classified using Stanford and DeBakey classification systems to indicate the aortic area involved. Early diagnosis and treatment of AAS are crucial for survival; however, diagnosis of IMH may be delayed and challenging due to atypical presentation, investigation findings, and case progression. In this report, we describe a case of delayed and challenging diagnosis of a Stanford type A IMH that was managed surgically with a good outcome.

Ethnic Disparities in CT Aortography Use for Diagnosing Acute Aortic Syndrome

Purpose

To determine whether CT aortography was performed in proportion to patient risk for acute aortic syndrome (AAS) and incidence of AAS for different ethnic groups.

Materials and Methods

All atraumatic thoracic aorta CT aortographic examinations performed in adults (age > 15 years) suspected of having AAS between January 2009 and December 2019 at Auckland City Hospital (New Zealand) were included. Patients were risk stratified using the aortic dissection detection risk score (ADD-RS). The primary outcomes were the ratio of CT aortography rates to rates of positive CT aortographic examinations and the incidence of AAS. Population census data were used to determine age-standardized incidence of AAS in the emergency department (ED).

Results

In total, 1646 CT aortographic examinations were performed in 1543 patients (mean age, 62 years ± 16 [SD]; 877 male patients). Māori (34% [68 of 203]) and Pacific Islanders (35% [80 of 229]) were more likely to be at high risk of AAS (ADD-RS > 1) compared with patients from other ethnic groups (25% [308 of 1214]); in the ED catchment population, age-standardized AAS incidence was significantly higher in Māori (6.9 per 100 000 person-years [95% CI: 4.3, 10.4]) and Pacific Islanders (5.3 [95% CI: 3.4, 7.8]) than in other ethnic groups (2.3 [95% CI: 1.8, 2.8]). Despite this higher incidence, disproportionately fewer CT aortographic examinations were requested in the ED for Māori (9.2 CT aortographic examinations per AAS diagnosis) and Pacific Islanders (9.2 CT aortographic examinations per AAS diagnosis) compared with other ethnic groups (13.8 CT aortographic examinations per AAS diagnosis).

Conclusion

Māori and Pacific Islanders were at disproportionately higher risk of AAS but had fewer requested CT aortographic examinations compared with other ethnic groups. This increased risk of AAS in Pacific Islander and indigenous Māori patients should be considered by clinicians when investigating AAS.Keywords: Ethnicity, Māori, Pacific Islander, Aortic Dissection Detection Risk Score, Acute Aortic Syndrome, Aortic Dissection, CT Angiography Supplemental material is available for this article. © RSNA, 2022.

Delayed surgical strategy for type A aortic dissection associated with acute hepatitis C cryoglobulinaemia

An aortic dissection is a condition resulting from a tunica intima tear of the aortic wall creating a ‘false lumen’. An acute Stanford type A (involves the aortic arch and/or ascending aorta) aortic dissection requires emergency surgical repair. To our knowledge, we report the first case in the literature where the treatment for an acute type A aortic dissection was intentionally delayed. This was decided following a multidisciplinary team discussion where it was agreed that the patient’s active hepatitis C infection should be treated prior to surgery. The patient re-presented to the hospital 4 months later with acute dyspnoea and orthopnoea where he was diagnosed with an acute-on-chronic type A aortic dissection with trachea compression. This was successfully treated with emergency surgery. However, the patient suffered residual dyspnoea, likely due to phrenic nerve injury demonstrating the impact of untreated aortic arch distension on the neighbouring trachea and phrenic nerve.

Trends in computed tomography aortography and acute aortic syndrome in an emergency department within Aotearoa New Zealand

OBJECTIVE

Acute aortic syndrome (AAS) comprises a triad of life-threatening aortic conditions that are difficult to diagnose because of their non-specific clinical presentations. Contrast-enhanced computed tomography aortography (CTA) has a high sensitivity and specificity for these conditions. However, under- and over-investigation of patients with suspected AAS using CTA carries significant risk. The aim of the present study was to evaluate the diagnostic imaging practices of CTA use for patients presenting to an ED with suspected AAS.

METHODS

All atraumatic thoracic CTAs performed on patients aged ≥15 years old with suspected AAS who presented to Auckland City Hospital between 2009 and 2019 were included. Outcomes of interest were the annual ED and population incidences of AAS, and the rate of CTAs performed.

RESULTS

A total of 1646 CTAs were included. There were 135 (8.2%) cases of at least one AAS diagnosis and 220 (13.4%) cases where an alternative diagnosis was made. The population-adjusted number of AAS diagnoses remained relatively stable over the study period, with a mean annual AAS incidence of 19.6 (95% confidence interval 9.9-33.7) per 100 000 patients, and 3.2 (95% confidence interval 1.6-5.4) per 100 000 population. The number of ED presentations increased during the study period, along with the population-adjusted rate of CTAs performed, from approximately 150 per 100 000 patients (2009) to 350 per 100 000 patients (2019).

CONCLUSIONS

Thoracic CTA use for investigating suspected AAS in our ED has recently increased. However, the annual incidence of AAS did not increase over the same period, but was higher than reported in overseas institutions.

Impact of unintentional coronary angiography on outcomes of emergency surgery in acute type A aortic dissection: a retrospective study

BACKGROUND

This study investigated the impact of coronary angiography on outcomes of emergency operation in acute type A aortic dissection (ATAAD) patients who were initially misdiagnosed as an acute coronary syndrome.

METHODS

From October 2016 to April 2019, 129 patients underwent emergency operation for ATAAD in our institution, including 21 patients (16.3%, coronary angiography group) who received preoperative coronary angiography without knowledge of the ATAAD, and the rest 108 did not (Non-coronary angiography group). Preoperative clinical characteristics, 30-day mortality and postoperative complications were compared. Multivariable logistic regression was performed to confirm the independent prognostic factors for short-term and long-term outcomes.

RESULTS

Patients undergoing coronary angiography had higher prevalence of preoperative hypotension or shock (61.9% vs 35.2%, P = 0.022), ischemic changes on electrocardiogram (66.7% vs 37.0%, P = 0.012), platelet inhibition (ADP-induced inhibition 92.0% vs 46.0%, P = 0.001), and coronary involvement (66.7% vs 30.6%, P = 0.002). 30-day mortality was 4.8% versus 9.3% (P = 0.84). Coronary angiography group had more intraoperative bleeding (1900 ml vs 1500 ml, P = 0.013) and chest-tube drainage on the first postoperative day (1040 ml vs 595 ml, P = 0.028). However, preoperative coronary angiography was not independent risk factors for 30-day mortality (OR 0.171, 95%CI 0.013-2.174, P = 0.173) and overall survival (HR 0.407; 95%CI 0.080-2.057; P = 0.277).

CONCLUSION

Patients undergoing coronary angiography carried a higher risk of preoperative hemodynamic instability, myocardial ischemia, and perioperative bleeding. However, unintentional coronary angiography did not have a significant impact on short-term and long-term outcomes of emergency surgery in ATAAD.

A Novel Serum Biomarker Model to Discriminate Aortic Dissection from Coronary Artery Disease

Background

The misdiagnosis of aortic dissection (AD) can lead to a catastrophic prognosis. There is currently a lack of stable serological indicators with excellent efficacy for the differential diagnosis of AD and coronary artery disease (CAD). A recent study has shown an association between AD and iron metabolism. Thus, we investigated whether iron metabolism could discriminate AD from CAD.

Methods

This retrospective and multicenter cross-sectional study investigated the efficacy of biomarkers of iron metabolism for the differential diagnosis of AD. We collected biomarkers of iron metabolism, liver function, kidney function, and other biochemistry test, and further, logistic regression analysis was applied.

Results

Between Oct. 8, 2020, and Mar. 1, 2021, we recruited 521 patients diagnosed with AD, CAD, and other cardiovascular diseases (OCDs) with the main symptoms of chest and back pain and assigned them to discovery set (n = 330) or validation set (n = 191). We found that six serum biomarkers, including serum iron, low-density lipoprotein, uric acid, transferrin, high-density lipoprotein, and estimated glomerular filtration rate, can serve as a novel comprehensive indicator (named FLUTHE) for the differential diagnosis of AD and CAD with a sensitivity of 0.954 and specificity of 0.905 to differentially diagnose AD and CAD more than 72 h past symptom onset.

Conclusion

Our findings provide insight into the role of iron metabolism in diagnosing and distinguishing AD, which might in the future be a key component in AD diagnosis. Furthermore, we establish a novel model named "FLUTHE" with higher efficiency, safety, and economy, especially for patients with chest pain for more than 72 h.

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.

Relation of Community-Level Socioeconomic Status to Delayed Diagnosis of Acute Type A Aortic Dissection

Acute type A aortic dissection requires timely diagnosis and intervention. Previous studies have examined risk factors associated with delayed diagnosis; however, the effect of socioeconomic status (SES) has not been previously studied. Our study examined the impact of various SES measures on time to diagnosis. We examined time to diagnosis in consecutive cases of acute type A aortic dissection at a single institution. SES variables included race/ethnicity, Medicaid eligibility, and residence in a zip code with an increased Distressed Communities Index-an aggregate measure of community SES. Delayed diagnosis was defined as time to diagnosis in the upper quartile of the study population (>6.6 hours). A model predicting risk factors for delayed diagnosis was created using multivariable logistic regression. Our study included 124 patients with a median time to diagnosis of 3.36 hours (interquartile range [IQR] 1.83 to 6.63). A total of 92 patients were in the nondelayed cohort (median diagnosis time of 2.59 hours, IQR 1.49 to 4.18) and 32 patients were in the delayed cohort (median diagnosis time of 15.57 hours, IQR 9.34 to 28.75). In multivariable logistic regression, residence in a high-Distressed Communities Index zip code was associated with diagnostic delay (adjusted odds ratio [aOR] 5.108, p = 0.008). Patient age (aOR 0.944, p = 0.011), chest pain at presentation (aOR 0.099, p = 0.004), back pain at presentation (aOR 0.247, p = 0.012), evidence of malperfusion syndrome (aOR 0.040, p <0.001), history of hyperlipidemia (aOR 3.507, p = 0.026), and history of congestive heart failure (aOR 0.061, p = 0.036) were also significantly associated. In conclusion, our findings suggest community-level SES affects time to diagnosis in acute type A aortic dissection.

Dual-processing theory helps to explain delay in diagnosis of Stanford type A aortic dissection

A woman in her 70s presented with chest pain, which was initially thought to be an acute coronary syndrome but subsequently felt to be pericarditis. Chest radiography and echocardiography demonstrated striking cardiomegaly and marked biatrial dilatation, likely secondary to undiagnosed restrictive cardiomyopathy. The patient remained well on the ward for some days with only mild discomfort and stable haemodynamics. CT of the thorax went on to unexpectedly demonstrate a Stanford type A aortic dissection. The patient was promptly transferred for emergent surgery but sadly died intraoperatively.Delayed or missed diagnosis of acute aortic dissection (AAD) is common. The dual-processing theory (DPT) of human judgement can be applied to medical decision making and used to explain this potential for diagnostic error in AAD diagnosis. A greater awareness of DPT and the role of heuristics and biases in medical decision making may help to reduce medical diagnostic error.

Incidental Finding of an Extensive Type B Aortic Dissection Extending to the Iliac Arteries

An aortic dissection is a life-threatening event that requires urgent evaluation. A dissection is defined as a tear in the innermost layer of the aortic wall forming a true and false lumen. This is normally diagnosed with a CT with contrast when clinical suspicion is present. Deciding whether urgent surgical intervention is required is key, as it may determine the survival of the patient. The treatment of type A aortic dissection involves emergent open-heart surgery. Medical treatment and clinical follow-up are recommended for uncomplicated type B dissections. In this report, we present a case of an extensive type B aortic dissection in an asymptomatic patient who required immediate surgical intervention.

Malperfusion in acute type A aortic dissection: how we handle the challenge?

Malperfusion syndrome (MPS) complicating acute type A aortic dissection (ATAAD) poses a continuing challenge and management dilemma for cardiovascular surgeons. MPS may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral, and/or limb ischemia with varying frequency and severity. Despite the continuous improvement in diagnosis and management strategies for MPS with ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable. The present review aimed to assess current evidence on ATAAD patients with MPS and how best to handle the challenge.

Angiopoietin 2 as a Novel Potential Biomarker for Acute Aortic Dissection

Biomarker-assisted diagnosis of acute aortic dissection (AAD) is important for initiation of treatment and improved survival. However, identification of biomarkers for AAD in blood is a challenging task. The present study aims to find the potential AAD biomarkers using a transcriptomic strategy. Arrays based genome-wide gene expression profiling were performed using ascending aortic tissues which were collected from AAD patients and healthy donors. The differentially expressed genes were validated using quantitative reverse transcriptase PCR (qRT-PCR) and western blot. The plasma levels of a potential biomarker, angiopoietin 2 (ANGPT2) were determined in case-control cohort (77 AAD patients and 82 healthy controls) by enzyme linked immunosorbent assay. Receiver operating characteristic curve (ROC) was used to evaluate the diagnostic power of ANGPT2 for AAD. Transcriptome data demonstrated that a total of 18 genes were significantly up-regulated and 28 genes were significantly down-regulated among AAD tissues (foldchange>3.0, p < 0.01). By bioinformatic analysis, we identified ANGPT2 as a candidate biomarker for blood-based detection of AAD. The qRT-PCR and protein expression demonstrated that ANGPT2 increased 2.4- and 4.2 folds, respectively in aortic tissue of AAD patients. Immunohistochemical staining demonstrated that ANGPT2 was markedly increased in intima of the aortic wall in AAD. Furthermore, ANGPT2 was significantly elevated in AAD patients as compared with controls (median 1625 vs. 383 pg/ml, p < 1E-6). ROC curve analysis showed that ANGPT2 was highly predictive of a diagnosis of type A AAD (area under curve 0.93, p < 1E-6). Sensitivity and specificity were 81 and 90%, respectively at the cutoff value of 833 pg/ml. In conclusion, ANGPT2 could be a promising biomarker for diagnosis of AAD; however, more studies are still needed to verify its specificity in diagnosing of AAD.

Outcomes of preoperative antiplatelet therapy in patients with acute type A aortic dissection

BACKGROUND

Acute type A aortic dissection (ATAAD) is life-threatening and requires immediate surgery. Sudden chest pain may lead to a risk of misdiagnosis as an acute coronary syndrome and may lead to subsequent antiplatelet therapy (APT). We used the Chinese Acute Aortic Syndrome (AAS) Collaboration Database to study the effects of APT on clinical outcomes.

METHODS

The AAS database is a retrospective multicentre database where 31 of 3092 patients had APT with aspirin or clopidogrel or both before surgery. Before and after propensity score matching (PSM), the incidence of complications and mortality was compared between APT and non-APT patients by using a logistic regression model. The sample remaining after PSM was 30 in the APT group and 80 in the non-APT group.

RESULTS

The sample remaining after matching was 30 in the APT group and 80 in the non-APT group. We found 10 cases with percutaneous coronary intervention in the APT group (33.3%). The APT group received more volume of packed red blood cells, 8.4 ± 6.05 units; plasma, 401.67 ± 727 ml, and platelet transfusion (14.07 ± 8.92 units). The drainage volume was much more in the APT group (5009.37 ± 2131.44 ml, p = .004). Mortality was higher in APT group (26% vs. 10%, p = .027). The preoperative APT was an independent predictor of mortality (odds ratio: 6.808, 95% confidence interval: 1.554-29.828, p = .011).

CONCLUSION

APT before ATAAD repair was associated with more transfusions and higher early mortality. The timing of surgery should be carefully considered based on the patient's status and the surgeon's experience.

Misdiagnosis of aortic dissection: A systematic review of the literature

BACKGROUND

Aortic dissection is a rare but potentially catastrophic condition. Misdiagnosis of aortic dissection is not uncommon as symptoms can overlap with other diagnoses.

OBJECTIVE

We conducted a systematic review to better understand the factors contributing to incorrect diagnosis of this condition.

METHODS

We searched MEDLINE and EMBASE for studies that evaluated the misdiagnosis of aortic dissection. The rate of misdiagnosis was pooled and results were narratively synthesized.

RESULTS

A total of 12 studies with were included with 1663 patients. The overall rate of misdiagnosis of aortic dissection was 33.8%. The proportion of patients presenting with chest pain, back pain and syncope were 67.5%, 24.8% and 6.8% respectively. The proportion of patients with pre-existing hypertension was 55.4%, 30.5% were smokers while the proportion of patients with coronary artery disease, previous cardiovascular surgery or surgical trauma and Marfan syndrome was 14.7%, 5.8%, and 3.7%, respectively. Factors related to misdiagnosis included the presence of symptoms and features associated with other diseases (such as acute coronary syndrome, stroke and pulmonary embolism), the absence of typical features (such as widened mediastinum on chest X-ray) or concurrent conditions such congestive heart failure. Factors associated with more accurate diagnosis included more comprehensive history taking and increased use of imaging.

CONCLUSIONS

Misdiagnosis in patients with an eventual diagnosis of aortic dissection affects 1 in 3 patients. Clinicians should consider aortic dissection as differential diagnosis in patients with chest pain, back pain and syncope. Imaging should be used early to make the diagnosis when aortic dissection is suspected.

Misdiagnosis of Thoracic Aortic Disease Occurs Commonly in Emergency Transfers

BACKGROUND

Acute aortic syndromes (AAS) are prone to misdiagnosis by facilities with limited diagnostic experience. We assessed long-term trends in misdiagnosis among patients transferred to a tertiary care facility with presumed AAS.

METHODS

Our institutional transfer center database was queried for emergency transfers in patients with a diagnosis of acute aortic syndromes or thoracic aortic aneurysm between January 2008 and May 2018. 784 patients were classified as emergency transfer for presumed AAS. Transferring diagnosis and actual diagnosis were compared through a review of physician notes and radiology reports from referring facilities and our center.

RESULTS

Mean age was 62 years, with 61% (n=478) men. Differences in transferring diagnosis and actual diagnosis were identified in 89 (11.4%) patients. Among misdiagnosed patients, the wrong classification of Stanford Type A or Type B dissections was identified among 24 (27%) patients. Twenty-three (26%) patients with a referring diagnosis of aortic dissection were found to have no dissection. Eighteen patients (20%) transferred for contained/impending rupture did not have signs of rupture. All misdiagnoses were secondary to misinterpretation of radiographic imaging, with motion artifacts (n=14, 16%) and post-surgical changes (n=22, 25%) being common sources of diagnostic error. Sixty-four (72%) patients underwent repeat scans at our facility due to limited access or sub-optimal quality of outside imaging.

CONCLUSIONS

While AAS misdiagnosis rates appear to be improving from the prior decade, there are opportunities for improved physician awareness through campaigns such as "Think Aorta." Centralized web-based imaging may prevent the costly hazards of unnecessary emergency transfer.

SP1-mediated transcriptional activation of PTTG1 regulates the migration and phenotypic switching of aortic vascular smooth muscle cells in aortic dissection through MAPK signaling

Pituitary tumor-transforming gene 1 (PTTG1) has been found to be associated with the process of cell proliferation and invasion, and is highly expressed in aortic dissection (AD). However, its potential role and underlying mechanism in AD remain uncertain. This study aims at elucidating the roles of specificity protein 1 (SP1) and PTTG1 in the migration and phenotypic switching of aortic vascular smooth muscle cells (VSMCs) in AD. Aortic samples were collected from 35 patients with AD for examination of PTTG1 expression in the tissues by qPCR, western blot and immunofluorescence. Human aortic vascular smooth muscle cells (HAVSMCs) were stimulated with platelet-derived growth factor-BB (PDGF-BB) to establish the cellular model of AD. PTTG1 expression in VSMCs was also examined by qPCR and western blot. Cell viability was detected by CCK-8, cell proliferation by EdU staining and cell migration by wound healing and transwell. Western blot was then performed to assay migration-related proteins. After interference with PTTG1, the levels of smooth muscle pthenotypic switch markers smooth muscle protein 22 alpha (SM22-α) and osteopontin (OPN) were detected by qPCR, western blot and immunofluorescence. The binding of SP1 and PTTG1 was verified with dual-luciferase reporter assay and chromatin immunoprecipitation assay (ChIP). PTTG1 overexpression was found in AD patients. Interference with PTTG1 attenuated the proliferation and migration of PDGF-BB-stimulated HAVSMCs, in addition to their switching from contractile phenotype to synthetic phenotype. Transcription factor SP1 was up-regulated in PDGF-BB-stimulated HAVSMCs, combined with PTTG1 promoter sequence and regulated PTTG1 expression, whose overexpression reversed the effects of PTTG1 interference on cell proliferation, migration and phenotypic switching. SP1 transcriptional activation of PTTG1 activated MAPK/ERK signaling pathway. In conclusion, SP1 transcriptional activation of PTTG1 regulates the migration and phenotypic transformation of HAVSMCs in AD by MAPK Signaling.

A Deep-Learning Algorithm-Enhanced System Integrating Electrocardiograms and Chest X-rays for Diagnosing Aortic Dissection

BACKGROUND

Chest pain is the most common symptom of aortic dissection (AD), but it is often confused with other prevalent cardiopulmonary diseases. We aimed to develop deep-learning models (DLMs) with electrocardiography (ECG) and chest x-ray (CXR) features to detect AD and evaluate their performance.

METHODS

This study included 43,473 patients in the emergency department (ED) between July 2012 and December 2019 for retrospective DLM development. A development cohort including 49,071 ED records (120 AD type A and 64 AD type B) was used to train DLMs for ECG and CXR, and 9904 independent ED records (40 AD type A and 34 AD type B) were used to validate DLM performance. Human-machine competitions of ECG and CXR were conducted. Patient characteristics and laboratory results were used to enhance the diagnostic accuracy. The DLM-enabled AD diagnostic process was prospectively evaluated in 25,885 ED visits.

RESULTS

The area under the curves (AUCs) of the ECG and CXR models were 0.918 and 0.857 for detecting AD in a human-machine competition, respectively, which were better than those of the participating physicians. In the validation cohort, the AUCs of the integrated model were 0.882, 0.960, and 0.813 in all AD, AD type A, and AD type B patients, respectively, with a sensitivity of 100.0% and a specificity of 81.7% for AD type A. In patients with chest pain and D-dimer tests, the DLM could predict more precisely, achieving a positive predictive value of 62.5% in the prospective evaluation.

CONCLUSIONS

DLMs may serve as decision-supporting tools for identification of AD and facilitate differential diagnosis in patients with acute chest pain.

Emergency CT misdiagnosis in acute aortic syndrome

OBJECTIVES

This cross-sectional study assessed the accuracy of emergency CT reports at presentation in acute aortic syndrome (AAS).

METHODS

Retrospective identification of cases of AAS presenting within a large health board with three acute hospitals receiving adult patients between January 2013 and December 2016. CT studies and reports at presentation were reviewed for discrepancies related to diagnosis, complications and classification by two cardiovascular radiologists. The specialist interest of the original reporters, clinically suspected diagnosis at referral for CT and technical adequacy of the scans were also assessed. False-positive diagnoses were identified and evaluated separately.

RESULTS

Among 88 consecutive confirmed cases of AAS at least one discrepancy was identified in 31% (n = 27), including failure to identify or misinterpretation of the AAS itself in 15% (n = 13), haemorrhage in 13% (n = 11), branch involvement in 9% (n = 8), and misclassification in 3% (n = 3). All discrepancies occurred among the 80% (n = 70) of cases reported by radiologists without specialist cardiovascular interest. 26% (n = 23/88) of AAS cases were not clinically suspected at referral for CT and although this was associated with suboptimal protocols, only 51% of CT scans among suspected cases were technically adequate. Seven false-positive diagnoses were identified, three of which related to motion artefact.

CONCLUSION

Significant discrepancies are common in the emergency CT assessment of positive cases AAS and this study highlights important pitfalls in CT technique and interpretation. The absence of discrepancies among radiologists with specialist cardiovascular interest suggests both suspected and confirmed cases warrant urgent specialist review.

ADVANCES IN KNOWLEDGE

CT angiography is central to the diagnosis of AAS; however, significant radiology discrepancies are common among non-specialists. This study highlights important pitfalls in both CT technique as well as interpretation and supports routine specialist cardiovascular imaging input in the emergency assessment of AAS.

Incidence and Outcome of Acute Myocardial Infarction in Patients With Aortic Dissection and Risk Factor Control

Background and Aims: The contradiction of management modality between acute myocardial infarction(AMI) and aortic dissection(AD) may result in clinical catastrophe. Data on risk factors, incidence, and outcome of AD and AMI are limited, and there have been no studies on the long-term outcomes of AMI in patients with AD. So we aimed to investigate long-term outcomes after AMI in patients with AD, and propose a useful diagnostic paradigm.

Methods: Consecutively enrolled patients with AD and AMI who were referred to our center from 2010 to 2017. Baseline patient characteristics, risk factors, all medical treatments, echocardiographic parameters, laboratory data, and treatment were recorded. All patients were followed up from the first hospitalization until a first heart event, death, or 17 March, 2018.

Results: 0.13% in AMI and 7.49% in AD patients had a concomitant diagnosis of AD and AMI. The average patient age was 53.3 ± 12.1 years and 84.6% were male. The most prevalent vascular risk factors were hypertension (69.2%) and current smoker (64.1%). Of all the 39 patients, 66.7% were managed surgically. Overall in-hospital mortality was 10.3%. The 30-day and 5-year fatality rates were 23.1% and 35.9%, but were higher for female than for male (66.7 vs. 30.3%, log-rank P = 0.045) on 5-year mortality. The overall survival of females was inferior to the males (log-rank P = 0.045).

Conclusions: Patients with AMI and AD exhibit high 5-year fatality rates. For these patients, surgical management tends to have lower mortality. Improved management of hypertension and smoking, may reduce future incidence rates.

Can D-Dimer in Low-Risk Patients Exclude Aortic Dissection in the Emergency Department?

BACKGROUND

Aortic dissection (AD) is a challenging diagnosis associated with severe mortality. However, acute AD is a rare clinical entity and can be overevaluated in the emergency department. D-dimer, both alone and in combination with the Aortic Dissection Detection Risk Score (ADD-RS), has been studied as a tool to evaluate for AD.

CLINICAL QUESTION

Can a negative D-dimer in low-risk patients exclude AD in the emergency department?

EVIDENCE REVIEW

Retrieved studies included three systematic review and meta-analyses and two prospective cohort studies. D-dimer was found to be highly sensitive for acute AD, with a sensitivity of 98.0%. The ADD-RS was also highly sensitive (95.7%) for AD. Two meta-analyses reported a combination of a negative D-dimer and ADD-RS < 1 to have a pooled sensitivity of 99.9% and 100% for acute aortic syndrome.

CONCLUSIONS

Neither D-dimer nor the ADD-RS alone provides adequate sensitivity to exclude acute AD. However, a negative D-dimer combined with an ADD-RS < 1 is likely sufficient to rule out AD. Even with these findings, physicians must place clinical judgment above laboratory testing or scoring systems when deciding whether to pursue a diagnosis of acute AD.

Aortic Dissection With Complete Occlusion of Left Main Coronary Artery Presenting as Acute ST-Segment Elevation Myocardial Infarction

Acute Aortic Dissection (AAD) is a life-threatening condition, which presents with a wide variety of symptoms ranging from being asymptomatic to sudden cardiac death. A retrograde extension of AAD can lead to partial or complete occlusion of coronary vessels, leading to an exceedingly rare presentation in the form of acute Myocardial Infarction (MI). A prognosis of AAD depends on prompt diagnosis and urgent surgical intervention to re-establish coronary blood flow. Here, we report a case of AAD, presenting as acute anterolateral wall MI, due to total occlusion of the left main coronary artery.

Percutaneous coronary intervention for left main coronary artery malperfusion in acute type A aortic dissection

The clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) malperfusion caused by acute type A aortic dissection (AAAD) remains largely unexplored. The aim of this study was to determine the clinical outcomes of patients undergoing PCI for LMCA malperfusion caused by AAAD. We examined nine consecutive patients undergoing PCI for LMCA malperfusion caused by AAAD between 1995 and 2020. The mean age was 55.4 ± 7.7 years. Eight patients presented cardiogenic shock, and five patients cardiopulmonary arrest. Two patients were diagnosed with AAAD before coronary angiography using computed tomography and transthoracic echocardiography, respectively, and in the other seven patients after coronary angiography using other modalities. Four patients underwent PCI on intra-aortic balloon pumping support, and four patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) support, including one patient on both. PCI was successful in eight patients, with final thrombolysis in myocardial infarction grade 2 or 3. The four patients on VA-ECMO did not undergo aortic dissection repair due to poor recovery of cardiac function and died during the hospital stay, and the other five patients had successful PCI, underwent aortic dissection repair, and remained alive at 5 year follow-up. In conclusion, LMCA malperfusion caused by AAAD seemed to have clinical presentations and electrocardiogram changes similar to acute coronary syndrome. PCI and subsequent surgical aortic repair saved the lives of all AAAD patients with LMCA malperfusion who had not required VA-ECMO.

Barriers and facilitators affecting implementation of the Canadian clinical practice guidelines for the diagnosis of acute aortic syndrome

BACKGROUND

Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The 2020 Canadian clinical practice guidelines for the diagnosis of AAS incorporate all available evidence into four key recommendations. In order to facilitate the implementation of these recommendations, a clinical decision aid was created. The objective of this study was to identify barriers and facilitators among physicians prior to implementation of the guideline recommendations in a multicentre step wedge cluster randomized control trial.

METHODS

We conducted semi-structured interviews with nine emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to guideline recommendation uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified.

RESULTS

Two themes and six subthemes encompassing 13 theoretical domains were identified. These included clinical decision-making support, awareness of the evidence, social factors, expected consequences, ability of physicians to acquire the necessary data and ease of use. A majority of interviewees anticipated that the guideline recommendations would support clinical decision making and more effectively risk-stratify patients. Other facilitators included endorsement of the guidelines by professional organizations and peers. Barriers to implementation include the fact that laboratory testing and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the clinical decision aid and concerns about test specificity were also identified as potential barriers to use.

CONCLUSION

Physicians were amenable to using the AAS guideline recommendations to support clinical decision-making and to reduce resource use. A structured intervention should be developed to address the identified barriers and leverage the facilitators in order to ensure successful implementation. Our findings may have implications for the implementation of other guidelines used in emergency departments.

State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection

Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.

Association between delayed transthoracic echocardiography and in-hospital mortality in type A acute aortic dissection-associated ST-segment elevated myocardial infarction

Background

This study evaluates the association between transthoracic echocardiography (TTE) timing and in-hospital mortality among individuals presenting with ST-segment elevated myocardial infarction (STEMI) complicating type A acute aortic dissection (TAAAD).

Methods

This cohort study obtained the data of previously published case reports from searches of PubMed (1990–2020), and adults with STEMI secondary to TAAAD were finally included. Delayed TTE (dTTE) exposure was defined as when the TTE test was made available after antithrombotic management for STEMI due to an initially missed diagnosis of TAAAD. The primary outcome of interest was in-hospital mortality, comparing individuals with dTTE and those with emergency TTE (eTTE). The odds ratio (OR) with 95% confidence interval (CI) were calculated to provide an estimate of association.

Results

A total of 109 individuals with a mean age of 56.7 [standard deviation (SD) 12.9] years, and of whom 75 were men (68.8%) presenting with STEMI complicating TAAAD were included. Of all patients, 68 (62.4%) had a dTTE test, which tended to be associated with increased in-hospital mortality after adjustment (OR, 2.320; 95% CI, 0.743–7.248). The association between dTTE and in-hospital death was significant only among patients presenting with a high-risk examination (HRE) (OR, 11.196; 95% CI, 1.322–94.803) and with surgical therapy (OR, 5.375; 95% CI, 1.080–26.700), and not among those presenting with negative HRE (OR, 0.150; 95% CI, 0.016–1.397) and no surgical therapy (OR, 0.177; 95% CI, 0.008–4.018).

Conclusions

This study found an association between dTTE and increased in-hospital mortality in TAAAD-associated STEMI patients with surgical management. This association warrants further investigation.

Serum Ceruloplasmin Is the Candidate Predictive Biomarker for Acute Aortic Dissection and Is Related to Thrombosed False Lumen: a Propensity Score-Matched Observational Case-Control Study

Acute aortic dissection (AAD), one of the fatal diseases observed at the department of vascular surgery, is associated with a great mortality rate at the early stage. Ceruloplasmin (CP) is the plasma protein that functions as a copper transporter. The current retrospective research was carried out to assess CP contents and to examine the possible part in diagnosing patients with AAD. In addition, propensity score matching (PSM) was also utilized for reducing the bias in case screening as well as the clinical confounders. Using PSM, this study included 85 pairs of AAD cases (Stanford A and B dissection) and matched controls, and their CP levels were also detected through enzyme-linked immunosorbent assay (ELISA). Additionally, the relative clinical data were extracted from participants included in this study. After PSM adjustment for clinical variables, including gender, age, body mass index (BMI), heart ratio (HR), smoking, hypertension, diabetes mellitus, coronary heart disease (CHD), and stroke, the serum CP contents among AAD cases were remarkably increased compared with those among the normal subjects. Besides, the CP contents showed independent association with the AAD risk. Typically, the CP level was significantly positively correlated with platelet (R = 0.329) or C-reactive protein (R = 0.340) level. Meanwhile, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.929 when CP was used to diagnose AAD, and the best threshold value was 36.82mg/dL. Serum CP content significantly increased in cases with thrombosed false lumen (FL) relative to those in patent FL cases. Results of logistic regression analysis suggested that a greater CP content indicated an increased thrombosed FL risk (OR = 1.11; 95% CI: 1.01-1.23; P = 0.040). Findings in this study suggest that serum ceruloplasmin contents evidently increased among acute aortic dissection cases. CP shows close correlation with the inflammatory factors among AAD cases. Further, CP may serve as the candidate biomarker to diagnose AAD and to identify an increased risk of thrombosed false lumen.

Aortic Dissection and Other Acute Aortic Syndromes: Diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression

Acute aortic dissection is the prototype of acute aortic syndromes (AASs), which include intramural hematoma, limited intimal tear, penetrating atherosclerotic ulcer, traumatic or iatrogenic aortic dissection, and leaking or ruptured aortic aneurysm. The manifestation is usually sudden and catastrophic with acutely severe tearing chest or back pain. However, clinical symptoms do not allow distinction between AAS types and other acute pathologic conditions. Diagnostic imaging is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of AASs. CT fast acquisition of volumetric datasets has become instrumental in diagnosis, surveillance, and intervention planning. Most critical findings affecting initial intervention and prognosis are obtained at CT, including involvement of the ascending aorta, primary intimal tear location, rupture, malperfusion, size and patency of the false lumen, complexity and extent of the dissection, maximum caliber of the aorta, and progression or postintervention complications. Involvement of the ascending aorta-Stanford type A-has the most rapid lethal complications and requires surgical intervention to affect its morbidity and mortality. Lesions not involving the ascending aorta-Stanford type B-have a lesser rate of complications in the acute phase. During the acute to longitudinal progression, various specific and nonspecific imaging findings are encountered, including pleural and pericardial effusions, fluid collections, progression including aortic enlargement, and postoperative changes that can be discerned at CT. A systematic analysis algorithm is proposed for CT of the entire aorta throughout the continuum of AASs into the chronic and posttreated disease state, which synthesizes and communicates salient findings to all care providers. Online supplemental material is available for this article. ^©RSNA, 2021.

Development and Validation of a Simplified Probability Assessment Score Integrated With Age-Adjusted d-Dimer for Diagnosis of Acute Aortic Syndromes

Background

When acute aortic syndromes (AASs) are suspected, pretest clinical probability assessment and d‐dimer (DD) testing are diagnostic options allowing standardized care. Guidelines suggest use of a 12‐item/3‐category score (aortic dissection detection) and a DD cutoff of 500 ng/mL. However, a simplified assessment tool and a more specific DD cutoff could be advantageous.

Methods and Results

In a prospective derivation cohort (n=1848), 6 items identified by logistic regression (thoracic aortic aneurysm, severe pain, sudden pain, pulse deficit, neurologic deficit, hypotension), composed a simplified score (AORTAs) assigning 2 points to hypotension and 1 to the other items. AORTAs≤1 and ≥2 defined low and high clinical probability, respectively. Age‐adjusted DD was calculated as years/age × 10 ng/mL (minimum 500). The AORTAs score and AORTAs≤1/age‐adjusted DD rule were validated in 2 patient cohorts: a high‐prevalence retrospective cohort (n=1035; 22% AASs) and a low‐prevalence prospective cohort (n=447; 11% AASs) subjected to 30‐day follow‐up. The AUC of the AORTAs score was 0.729 versus 0.697 of the aortic dissection detection score (P=0.005). AORTAs score assessment reclassified 16.6% to 25.1% of patients, with significant net reclassification improvement of 10.3% to 32.7% for AASs and −8.6 to −17% for alternative diagnoses. In both cohorts, AORTAs≥2 had superior sensitivity and slightly lower specificity than aortic dissection detection ≥2. In the prospective validation cohort, AORTAs≤1/age‐adjusted DD had a sensitivity of 100%, a specificity of 48.6%, and an efficiency of 43.3%.

Conclusions

AORTAs is a simplified score with increased sensitivity, improved AAS classification, and minor trade‐off in specificity, amenable to integration with age‐adjusted DD for diagnostic rule‐out.

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.

Usefulness of point-of-care ultrasound in the atypical presentation of aortic dissection: a case series and brief review of literature

Acute aortic dissection represents a surgical emergency that, in most cases, may present an atypical and non-specific clinic, making the diagnosis difficult and late. Computed tomography angiography represents the gold standard for diagnosis, but different ultrasound techniques are able to provide valuable additional information related to diagnosis, and optimize therapy and prognostic assessment. In this case series, we describe different atypical patterns of aortic dissection, associated to non-diagnostic D-Dimer levels. These atypical conditions escape recognized diagnostic algorithms for the diagnosis of aortic dissection, although the incidence of such events is far from negligible. A clinical approach in the emergency setting that provides for a systematic and standardized use of bedside ultrasound could help reduce the incidence of errors and diagnostic delay, addressing the gold standard instrumental diagnostics for the reference pathology.

An early aortic dissection screening model and applied research based on ensemble learning

Background

As a particularly dangerous and rare cardiovascular disease, aortic dissection (AD) is characterized by complex and diverse symptoms and signs. In the early stage, the rate of misdiagnosis and missed diagnosis is relatively high. This study aimed to use machine learning technology to establish a fast and accurate screening model that requires only patients' routine examination data as input to obtain predictive results.

Methods

A retrospective analysis of the examination data and diagnosis results of 53,213 patients with cardiovascular disease was conducted. Among these samples, 802 samples had AD. Forty-two features were extracted from the patients' routine examination data to establish a prediction model. There were five ensemble learning models applied to explore the possibility of using machine learning methods to build screening models for AD, including AdaBoost, XGBoost, SmoteBagging, EasyEnsemble and XGBF. Among these, XGBF is an ensemble learning model that we propose to deal with the imbalance of the positive and negative samples. The seven-fold cross validation method was used to analyze and verify the performance of each model. Due to the imbalance of the samples, the evaluation indicators were sensitivity and specificity.

Results

Comparative experiments showed that the sensitivity of XGBF was 80.5%, which was better than the 16.1% of AdaBoost, 15.7% of XGBoost, 78.0% of SmoteBagging and 77.8% of EasyEnsemble. Additionally, XGBF had relatively high specificity, and the training time consumption was short. Based on these three indicators, XGBF performed best, and met the application requirements, which means through careful design, we can use machine learning technology to achieve early AD screening.

Conclusions

Through reasonable design, the ensemble learning method can be used to build an effective screening model. The XGBF has high practical application value for screening for AD.

A simple intervention to reduce your chance of missing an acute aortic dissection

INTRODUCTION

Acute aortic dissection (AAD) is a time sensitive, difficult to diagnose, aortic emergency. We sought to explore the quality of history taking in AAD and assess its impact on misdiagnosis.

METHODS

We studied a retrospective cohort of patients >18 years old who presented to two tertiary care emergency departments from January 1st 2004 - December 31st 2012 and were diagnosed with an acute aortic dissection (AAD) on CT, MRI or TEE. Trained reviewers' extracted data using a standardized data collection form. The definitions of 5 pain characteristics - character, onset, duration, quality, and radiation were defined a priori.

RESULTS

Data were collected for 194 cases of acute aortic dissection with a mean age of 65(SD 14.1) and 66.7% male, 34(17.6%) missed on initial presentation. Only 20(14.8%) patients were asked all 5 questions. The most common initial incorrect diagnosis were acute coronary syndrome (16, 47%), pulmonary embolism (5, 14.7%) and stroke (4, 11.7%). If <2 questions were asked 1 in 5 cases were missed, 4 times greater than if >2 were asked (P < 0.01).

CONCLUSION

Clinicians should ask and document the character, onset, duration, radiation and severity of pain in any patient presenting with chest, abdominal or flank pain. A focused history still remains the keystone to reducing misdiagnosis.

An uncommon acute type A aortic dissection mimicking an inferior STEMI

Aortic dissection in the most common fatal disease affecting the aorta. Ascending aortic dissection can lead to coronary malperfusion causing myocardial infarction with ST elevation. The distinction between aortic dissection and a primary myocardial infarction can be difficult because both conditions can have similar presentations. Making the right diagnosis is essential because the therapies used to treat myocardial infarction can be fatal for patients with aortic dissection. Emergency transthoracic echography presents a rapid imaging procedure that provides strong hints of the coexistence of these two diseases, leading to further imaging examination and prevent inappropriate administration of treatments that could cause catastrophic outcome. We report a case of a 62-year-old man admitted to our hospital with chest pain, who was diagnosed as inferior wall myocardial infarction based on electrocardiographic findings. The diagnosis was reassessed due to a significant aortic regurgitation and an intimal tear in the ascending aorta on transthoracic echocardiography. Computed tomography angiogram of the chest and transesophageal echography fully confirmed the presence of ascending aortic dissection. Emergency surgery was successfully performed and the patient recovered well.

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.