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Briggs B, Cline D. Diagnosing aortic dissection: A review of this elusive, lethal diagnosis. J Am Coll Emerg Physicians Open 2024; 5:e13225. [PMID: 38983974 PMCID: PMC11231041 DOI: 10.1002/emp2.13225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/11/2024] Open
Abstract
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.
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Affiliation(s)
- Blake Briggs
- Division of Emergency MedicineDepartment of SurgeryUniversity of Tennessee Graduate School of MedicineKnoxvilleTennesseeUSA
| | - David Cline
- Department of Emergency MedicineWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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Ren S, Essat M, Pandor A, Goodacre S, Ren S, Clowes M, Bima P, Toyofuku M, McLatchie R, Bossone E. Diagnostic accuracy of the aortic dissection detection risk score alone or with D-dimer for acute aortic syndromes: Systematic review and meta-analysis. PLoS One 2024; 19:e0304401. [PMID: 38905181 PMCID: PMC11192411 DOI: 10.1371/journal.pone.0304401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/11/2024] [Indexed: 06/23/2024] Open
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of the aortic dissection detection risk score (ADD-RS) used alone or in combination with D-dimer for detecting acute aortic syndrome (AAS) in patients presenting with symptoms suggestive of AAS. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library from inception to February 2024. Additionally, the reference lists of included studies and other systematic reviews were thoroughly searched. All diagnostic accuracy studies that assessed the use of ADD-RS alone or with D-Dimer for diagnosing AAS compared with a reference standard test (e.g. computer tomographic angiography (CTA), ECG-gated CTA, echocardiography, magnetic resonance angiography, operation, or autopsy) were included. Two reviewers independently selected and extracted data. Risk of bias was appraised using QUADAS-2 tool. Data were synthesised using hierarchical meta-analysis models. RESULTS We selected 13 studies from the 2017 citations identified, including six studies evaluating combinations of ADD-RS alongside D-dimer>500ng/L. Summary sensitivities and specificities (95% credible interval) were: ADD-RS>0 94.6% (90%, 97.5%) and 34.7% (20.7%, 51.2%), ADD-RS>1 43.4% (31.2%, 57.1%) and 89.3% (80.4%, 94.8%); ADD RS>0 or D-Dimer>500ng/L 99.8% (98.7%, 100%) and 21.8% (12.1%, 32.6%); ADD RS>1 or D-Dimer>500ng/L 98.3% (94.9%, 99.5%) and 51.4% (38.7%, 64.1%); ADD RS>1 or ADD RS = 1 with D-dimer>500ng/L 93.1% (87.1%, 96.3%) and 67.1% (54.4%, 77.7%). CONCLUSIONS Combinations of ADD-RS and D-dimer can be used to select patients with suspected AAS for imaging with a range of trade-offs between sensitivity (93.1% to 99.8%) and specificity (21.8% to 67.1%).
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Affiliation(s)
- Sa Ren
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Munira Essat
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Abdullah Pandor
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Steve Goodacre
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Shijie Ren
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Mark Clowes
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Paolo Bima
- Department of Medical Science, University of Turin, Turin, Italy
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Rachel McLatchie
- Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Eduardo Bossone
- Department of Public Health, University of Naples “Federico II”, Naples, Italy
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Reed MJ. Diagnosis and management of acute aortic dissection in the emergency department. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38708978 DOI: 10.12968/hmed.2023.0366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Acute aortic dissection is often misdiagnosed as a result of its atypical presentations. It affects 4000 patients a year in the UK of all ages, not just older patients, with increasing numbers of cases expected in the future because of the ageing population. Dissection of the aortic wall leads to sudden, severe pain, and commonly end-organ symptoms which must be recognised. Acute aortic dissection can be challenging to diagnose in the emergency department because of the multitude of possible presentations and the need for selective testing with Computed Tomography Angiography (CTA). Clinicians often miss acute aortic dissection because it is not considered in the differential diagnosis, and the challenge lies in identifying acute aortic dissection in a sea of complaints of chest, back and abdominal pain. There are several ways to improve diagnosis, including awareness campaigns, better education about patients in which to consider acute aortic dissection, and improved detection strategies including which patients should receive CTA. Clinical decision tools and biomarkers could help, but further research is required and is a research focus in emergency medicine. Once diagnosed, blood pressure control, analgesia and urgent surgery or transfer to enable this to occur with minimal delay is required.
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Affiliation(s)
- Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
- Acute Care Edinburgh, Usher Institute, University of Edinburgh, Edinburgh, UK
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McLatchie R, Reed MJ, Freeman N, Parker RA, Wilson S, Goodacre S, Cowan A, Boyle J, Clarke B, Clarke E. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. Emerg Med J 2024; 41:136-144. [PMID: 37945311 DOI: 10.1136/emermed-2023-213266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. We describe characteristics of ED attendances with symptoms potentially associated with AAS, diagnostic performance of clinical decision tools (CDTs) and physicians and yield of CT aorta angiogram (CTA). METHODS This was a multicentre observational cohort study of adults attending 27 UK EDs between 26 September 2022 and 30 November 2022, with potential AAS symptoms: chest, back or abdominal pain, syncope or symptoms related to malperfusion. Patients were preferably identified prospectively, but retrospective recruitment was also permitted. Anonymised, routinely collected patient data including components of CDTs, was abstracted. Clinicians treating prospectively identified patients were asked to record their perceived likelihood of AAS, prior to any confirmatory testing. Reference standard was radiological or operative confirmation of AAS. 30-day electronic patient record follow-up evaluated whether a subsequent diagnosis of AAS had been made and mortality. RESULTS 5548 patients presented, with a median age of 55 years (IQR 37-72; n=5539). 14 (0.3%; n=5353) had confirmed AAS. 10/1046 (1.0%) patients in whom the ED clinician thought AAS was possible had AAS. 5/147 (3.4%) patients in whom AAS was considered the most likely diagnosis had AAS. 2/3319 (0.06%) patients in whom AAS was considered not possible did have AAS. 540 (10%; n=5446) patients underwent CT, of which 407 were CTA (7%). 30-day follow-up did not reveal any missed AAS diagnoses. AUROC (area under the receiver operating characteristic) curve for ED clinician AAS likelihood rating was 0.958 (95% CI 0.933 to 0.983, n=4006) and for individual CDTs were: Aortic Dissection Detection Risk Score (ADD-RS) 0.674 (95% CI 0.508 to 0.839, n=4989), AORTAs 0.689 (95% CI 0.527 to 0.852, n=5132), Canadian 0.818 (95% CI 0.686 to 0.951, n=5180) and Sheffield 0.628 (95% CI 0.467 to 0.788, n=5092). CONCLUSION Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer. TRIAL REGISTRATION NUMBER NCT05582967; NCT05582967.
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Affiliation(s)
- Rachel McLatchie
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
- Acute Care Edinburgh, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Nicola Freeman
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah Wilson
- Emergency Department, Wexham Park Hospital, Slough, Frimley Health NHS Foundation Trust, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Alicia Cowan
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jessica Boyle
- The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Benjamin Clarke
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ellise Clarke
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
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Carter JM, Tom RB, Sunesra R, Bilby NJ, Mireles B, Paul KK, Koscumb PA, Cox MW, Jehle DV. D-dimer as a Rule-Out for Aortic Dissection. Cureus 2023; 15:e50170. [PMID: 38186548 PMCID: PMC10771797 DOI: 10.7759/cureus.50170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Acute aortic dissection (AAD) represents a significant diagnostic challenge with a high mortality rate if not treated promptly. This challenge arises from the diverse clinical presentations of AAD, and its symptom overlap with other medical conditions. Although both helical CT and transesophageal echocardiography are reliable diagnostic tools for AAD, they are not feasible for every suspected case. Furthermore, limited research on D-dimer's utility in ruling out AAD has been conducted due to the condition's rarity. Methods This study utilizes the TriNetX database (https://trinetx.com/), encompassing data from 54 healthcare organizations across the United States over the past two decades from 85 million patients. The objective is to evaluate the sensitivity of an elevated D-dimer level in diagnosing AAD across a much larger patient cohort than previously studied. Results Retrospectively analyzing this dataset, there were 1,319 patients identified with a confirmed AAD who had undergone D-dimer testing within a day of diagnosis. Of these, 1,252 patients exhibited D-dimer levels exceeding 400 ng/ml while 1,227 had levels surpassing 500 ng/ml. Notably, a D-dimer cutoff of 400 ng/ml demonstrated a sensitivity of 0.949 while a 500 ng/ml cutoff yielded a sensitivity of 0.930. Conclusion This large retrospective cohort study demonstrates that a blood D-dimer level is highly sensitive in assaying for AAD. The D-dimer levels analyzed showed a remarkable sensitivity in ruling out AAD, avoiding the need for more invasive testing in low-risk patients.
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Affiliation(s)
- Jeremy M Carter
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Roshan B Tom
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Raheed Sunesra
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Nathaniel J Bilby
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Blake Mireles
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Krishna K Paul
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Paul A Koscumb
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Mitchell W Cox
- Department of Vascular Surgery, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Dietrich V Jehle
- Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Bima P, Giamello JD, Rubiolo P, Risi F, Balzaretti P, Lauria G, Vallino D, Lupia E, Morello F. Clinical Presentation and Emergency Department Management Checkpoints of Acute Aortic Syndromes during the First Two Waves of the COVID-19 Pandemic. J Clin Med 2023; 12:6601. [PMID: 37892739 PMCID: PMC10607079 DOI: 10.3390/jcm12206601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
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.
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Affiliation(s)
- Paolo Bima
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy; (P.B.); (E.L.)
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
- Cardiovascular Research Institute Basel (CRIB), 4056 Basel, Switzerland
| | - Jacopo Davide Giamello
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
- Medicina d’Urgenza, Ospedale S. Croce e Carle, 12100 Cuneo, Italy
| | - Paolo Rubiolo
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
| | - Francesca Risi
- Dipartimento di Emergenza e Accettazione, Ospedale Mauriziano, 10128 Torino, Italy
| | - Paolo Balzaretti
- Dipartimento di Emergenza e Accettazione, Ospedale Mauriziano, 10128 Torino, Italy
| | - Giuseppe Lauria
- Medicina d’Urgenza, Ospedale S. Croce e Carle, 12100 Cuneo, Italy
| | - Domenico Vallino
- Dipartimento di Emergenza e Accettazione, Ospedale Mauriziano, 10128 Torino, Italy
| | - Enrico Lupia
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy; (P.B.); (E.L.)
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
| | - Fulvio Morello
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy; (P.B.); (E.L.)
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy; (J.D.G.)
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Lumbreras-Fernández B, Vicente Bártulos A, Fernandez-Felix BM, Corres González J, Zamora J, Muriel A. Improvement in the management of suspected acute aortic syndrome in the emergency room through a clinical algorithm and study of predictive factors. RADIOLOGIA 2023; 65:423-430. [PMID: 37758333 DOI: 10.1016/j.rxeng.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/15/2022] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Acute aortic syndrome (AAS) is uncommon and difficult to diagnose, with great variability in clinical presentation. To develop a computerized algorithm, or clinical decision support system (CDSS), for managing and requesting imaging in the emergency department, specifically computerized tomography of the aorta (CTA), when there is suspicion of AAS, and to determine the effect of implementing this system. To determine the factors associated with a positive radiological diagnosis that improve the predictive capacity of CTA findings. MATERIALS AND METHODS After developing and implementing an evidence-based algorithm, we studied suspected cases of AAS. Chi-squared test was used to analyze the association between the variables included in the algorithm and radiological diagnosis, with 3 categories: no relevant findings, positive for AAS, and alternative diagnoses. RESULTS 130 requests were identified; 19 (14.6%) had AAS and 34 (26.2%) had a different acute pathology. Of the 19 with AAS, 15 had been stratified as high risk and 4 as intermediate risk. The probability of AAS was 3.4 times higher in patients with known aortic aneurysm (P = .021, 95% CI 1.2-9.6) and 5.1 times higher in patients with a new aortic regurgitation murmur (P = .019, 95% CI 1.3-20.1). The probability of having an alternative severe acute pathology was 3.2 times higher in patients with hypotension or shock (P = .02, 95% CI 1.2-8.5). CONCLUSION The use of a CDSS in the emergency department can help optimize AAS diagnosis. The presence of a known aortic aneurysm and new-onset aortic regurgitation were shown to significantly increase the probability of AAS. Further studies are needed to establish a clinical prediction rule.
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Affiliation(s)
| | - A Vicente Bártulos
- Servicio de Radiología de Urgencias, Hospital Universitario Ramón y Cajal, Madrid, Centro de Investigación Biomédica en Red Enfermedades respiratorias (CIBERES), Madrid, Spain
| | - B M Fernandez-Felix
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - J Corres González
- Servicio de Urgencias, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Zamora
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, España, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - A Muriel
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, IRYCIS, CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Departamento de Enfermería de la Universidad de Alcalá, Madrid, Spain
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Zhang H, Yuan N, Guo J, Hou M. Comparisons of potential values of D-dimer and the neutrophil- to-lymphocyte ratio in patients with suspected acute aortic syndrome. Am J Emerg Med 2023; 69:44-51. [PMID: 37058980 DOI: 10.1016/j.ajem.2023.03.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/04/2023] Open
Abstract
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.
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Affiliation(s)
- Haixia Zhang
- Department of Laboratory Medicine, Tianjin Chest Hospital, 261 South Taierzhuang Road, Tianjin 300222, China.
| | - Ning Yuan
- Department of Laboratory Medicine, Tianjin Chest Hospital, 261 South Taierzhuang Road, Tianjin 300222, China
| | - Jie Guo
- Department of Laboratory Medicine, Tianjin Chest Hospital, 261 South Taierzhuang Road, Tianjin 300222, China
| | - Min Hou
- Department of Laboratory Medicine, Tianjin Chest Hospital, 261 South Taierzhuang Road, Tianjin 300222, China.
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Otani T, Abe T, Ichiba T, Kashiwa K, Naito H. D-dimer measurement is useful irrespective of time from the onset of acute aortic syndrome symptoms. Am J Emerg Med 2023; 71:7-13. [PMID: 37315439 DOI: 10.1016/j.ajem.2023.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND In acute aortic syndrome (AAS) screening, D-dimer is a well-established biomarker whose usefulness has been scarcely studied with respect to its measurement timing. We aimed to evaluate the effectiveness of D-dimer-based AAS screening focused on the time interval between AAS onset and D-dimer measurement. METHODS We retrospectively analyzed consecutive patients diagnosed with AAS who visited our hospital between 2011 and 2021. For the primary analysis, we divided patients according to the quartiles of the time interval between AAS symptom onset and D-dimer measurement. D-dimer level ≥ 0.5 μg/mL and age-adjusted D-dimer ≥ [age (years) × 0.01] μg/mL (minimum of 0.5 μg/mL) were defined as positive. The primary endpoint was the comparative ability of D-dimer to detect AAS within and between each time quartile. In an exploratory secondary analysis, we reported patient and AAS characteristics in the subgroup of patients who underwent repeat D-dimer measurement within 48 h of the first D-dimer measure. RESULTS The 273 AAS patients were divided into four groups based on quartiles of the time interval (Group 1, ≤1 h; Group 2, 1-2 h; Group 3, 2-5 h; and Group 4, >5 h). There were no significant differences in D-dimer levels or in the proportions with positive D-dimer (Group 1: 97%, Group 2: 96%, Group 3: 99%, Group 4: 99%; P = 0.76) or positive age-adjusted D-dimer (Group 1: 96%, Group 2: 90%, Group 3: 96%, Group 4: 97%; P = 0.32) between the groups. Of the 147 patients who had D-dimer re-measured, nine had negative D-dimer levels on either the primary or secondary measurement. Of these nine patients, eight had AAS with a thrombosed false lumen and one with a patent false lumen had a short length of dissection. In all nine patients, D-dimer levels remained low (maximum of 1.4 μg/mL). CONCLUSION D-dimer levels were elevated from the early stages of AAS. The clinical utility of D-dimer is not affected by the time interval from AAS onset to D-dimer measurement, but rather is influenced by AAS characteristics.
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Affiliation(s)
- Takayuki Otani
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima-city, Hiroshima 730-8518, Japan.
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, Ibaraki 300-2622, Japan; Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8577, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima-city, Hiroshima 730-8518, Japan
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima-city, Hiroshima 730-8518, Japan
| | - Hiroshi Naito
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima-city, Hiroshima 730-8518, Japan
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11
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Ohle R, McIsaac S, Van Drusen M, Regis A, Montpellier O, Ludgate M, Bodunde O, Savage DW, Yadav K. Evaluation of the Canadian Clinical Practice Guidelines Risk Prediction Tool for Acute Aortic Syndrome: The RIPP Score. Emerg Med Int 2023; 2023:6636800. [PMID: 37275621 PMCID: PMC10234704 DOI: 10.1155/2023/6636800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 06/07/2023] Open
Abstract
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.
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Affiliation(s)
- Robert Ohle
- The Department of Emergency Medicine, Health Science North Research Institute, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Sarah McIsaac
- Department of Critical Care, Department of Anaesthesia, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Madison Van Drusen
- Department of Undergraduate Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aaron Regis
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Owen Montpellier
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Mackenzie Ludgate
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Oluwadamilola Bodunde
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - David W. Savage
- Clinical Sciences Division, Nortner Ontario School of Medicine University, Thunder Bay, Ontario, Canada
| | - Krishan Yadav
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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12
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McLatchie R, Wilson S, Reed M, Ticehurst F, Easterford K, Alawiye S, Cowan A, Gupta A. Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis. EMERGENCY CARE JOURNAL 2023. [DOI: 10.4081/ecj.2023.11153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Objectives: To understand why the diagnosis of AAS is missed in the ED, and to characterise the presenting features of cases in which a diagnosis of AAS was missed.
Methods: A retrospective case series cohort study was performed, identifying and analysing cases where AAS was misdiagnosed in three UK EDs between 1st January 2011 and 31st December 2020.
Results: 43 cases were included, 22 of which were type A aortic dissections. The most common incorrect presumed diagnoses made were acute coronary syndrome (28%), pulmonary embolism (12%) and ‘non-specific chest pain’ (12%). In 31 cases (72%) there was no evidence from the notes that the clinician had considered AAS in the differential diagnosis. In 10 cases (23%), AAS was considered, but the clinician was falsely reassured by atypical or resolved symptoms, clinical examination, or normal chest x-ray.
Conclusions: ED clinicians may miss AAS by not considering it as a possibility, being falsely reassured by atypical or resolved symptoms, or mistaking it for other more common conditions. Further prospective work is necessary to establish the role of diagnostic aids and biomarkers in UK EDs.
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13
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Morello F, Santoro M, Giachino F, Caciolli F, Capretti E, Castelli M, Pivetta E, Nazerian P, Lupia E. Pre-Test Probability Assessment and d-Dimer Based Evaluation in Patients with Previous Acute Aortic Syndrome. Medicina (B Aires) 2023; 59:medicina59030548. [PMID: 36984549 PMCID: PMC10057941 DOI: 10.3390/medicina59030548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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Affiliation(s)
- Fulvio Morello
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy
- Correspondence: ; Tel.: +39-011-6337009
| | - Marco Santoro
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy
| | - Francesca Giachino
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy
| | - Francesca Caciolli
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy
| | - Elisa Capretti
- Dipartimento di Emergenza e Accettazione, A.O.U. Careggi, 50134 Firenze, Italy
| | - Matteo Castelli
- Dipartimento di Emergenza e Accettazione, A.O.U. Careggi, 50134 Firenze, Italy
| | - Emanuele Pivetta
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy
| | - Peiman Nazerian
- Dipartimento di Emergenza e Accettazione, A.O.U. Careggi, 50134 Firenze, Italy
| | - Enrico Lupia
- S.C. Medicina d’Urgenza U (MECAU), Ospedale Molinette, A.O.U. Città della Salute e della Scienza, 10126 Torino, Italy
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, 10126 Torino, Italy
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14
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Perone F, Guglielmo M, Coceani M, La Mura L, Dentamaro I, Sabatino J, Gimelli A. The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management. Diagnostics (Basel) 2023; 13:diagnostics13040650. [PMID: 36832136 PMCID: PMC9954850 DOI: 10.3390/diagnostics13040650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.
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Affiliation(s)
- Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, Castel Morrone, 81020 Caserta, Italy
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Michele Coceani
- Diagnostic and Interventional Cardiology Unit, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II of Naples, 80133 Naples, Italy
| | - Ilaria Dentamaro
- Cardiology Department and Cardiovascular Imaging Laboratory, Hospital Miulli, 70124 Bari, Italy
| | - Jolanda Sabatino
- Pediatric and Congenital Cardiology Unit, Department for Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
- Correspondence:
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15
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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16
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 376] [Impact Index Per Article: 188.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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17
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Morello F, Bima P, Castelli M, Nazerian P. Acute aortic syndromes: An internist's guide to the galaxy. Eur J Intern Med 2022; 106:45-53. [PMID: 36229285 DOI: 10.1016/j.ejim.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/05/2022] [Accepted: 10/05/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Fulvio Morello
- S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Dipartimento di Scienze Mediche, Università degli Studi di Torino, Italy
| | - Paolo Bima
- S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matteo Castelli
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
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Lumbreras-Fernández B, Vicente Bártulos A, Fernandez-Felix B, Corres González J, Zamora J, Muriel A. Mejora en el manejo de la sospecha del síndrome aórtico agudo en urgencias mediante un algoritmo clínico y el estudio de factores predictivos. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Morello F, Bima P, Pivetta E, Santoro M, Catini E, Casanova B, Leidel BA, de Matos Soeiro A, Nestelberger T, Mueller C, Grifoni S, Lupia E, Nazerian P. Development and Validation of a Simplified Probability Assessment Score Integrated With Age-Adjusted d-Dimer for Diagnosis of Acute Aortic Syndromes. J Am Heart Assoc 2021; 10:e018425. [PMID: 33474974 PMCID: PMC7955418 DOI: 10.1161/jaha.120.018425] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Fulvio Morello
- S.C.U. Medicina d'UrgenzaOspedale Molinette, A.O.U. Città della Salute e della Scienza Torino Italy.,Dipartimento di Scienze Mediche Università degli Studi di Torino Torino Italy
| | - Paolo Bima
- S.C.U. Medicina d'UrgenzaOspedale Molinette, A.O.U. Città della Salute e della Scienza Torino Italy
| | - Emanuele Pivetta
- S.C.U. Medicina d'UrgenzaOspedale Molinette, A.O.U. Città della Salute e della Scienza Torino Italy
| | - Marco Santoro
- S.C.U. Medicina d'UrgenzaOspedale Molinette, A.O.U. Città della Salute e della Scienza Torino Italy
| | - Elisabetta Catini
- Department of Emergency Medicine Careggi University Hospital Firenze Italy
| | - Barbara Casanova
- Department of Emergency Medicine Careggi University Hospital Firenze Italy
| | - Bernd A Leidel
- Department of Emergency Medicine Charité-Universitätsmedizin Berlin Berlin Germany
| | | | - Thomas Nestelberger
- Cardiovascular Research Institute University Hospital Basel Basel Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute University Hospital Basel Basel Switzerland
| | - Stefano Grifoni
- Department of Emergency Medicine Careggi University Hospital Firenze Italy
| | - Enrico Lupia
- S.C.U. Medicina d'UrgenzaOspedale Molinette, A.O.U. Città della Salute e della Scienza Torino Italy.,Dipartimento di Scienze Mediche Università degli Studi di Torino Torino Italy
| | - Peiman Nazerian
- Department of Emergency Medicine Careggi University Hospital Firenze Italy
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