How to prevent inadvertent emergency anticoagulation in acute type A aortic dissection: when in doubt, don't

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle's syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.

Time is of the essence: where can we improve care in acute aortic dissection?

OBJECTIVES

In acute aortic dissection type A various components of the diagnostic and logistic pathways may affect the time to definitive treatment. This study aimed to characterize these components and to identify factors delaying the optimal management within our institutional referral network.

METHODS

Between January 2017 and January 2020, 96 consecutive patients with classical aortic dissection type A were admitted (28%) or referred (72%) to our tertiary care centre and analysed retrospectively. Data are presented as medians (25th-75th quartile).

RESULTS

Median age was 66 years (56-74), 63% were male. Most of the patients were primarily admitted to a cardiology department (40%), whereas about a fourth were admitted to departments for internal medicine (26%) and general surgery (27%). The median interval from the onset of symptoms to hospital admission was 2.1 (1-4.4) h. From admission to confirmed diagnosis it took 2.1 (0.6-9.5) h and the median interval from confirmed diagnosis to admission at our specialized tertiary care aortic centre was 1.5 (0.9-2.4) h. Following admission to our centre, 1.1 (0.5-1.9) h passed until the induction of anaesthesia and 0.8 (0.0-1.1) h until the start of surgery. The total interval from the onset of symptoms to the start of surgery was 7.6 h (5.1-12.3).

CONCLUSIONS

The marked variability of the time from symptoms to diagnosis at any medical facility demonstrates the importance of awareness in the optimization of the treatment of acute aortic dissection type A.

From ER to OR-Type A aortic dissection delay dilemma

BACKGROUND AND AIM OF STUDY

Aortic dissection (AD) remains a life-threatening and time-critical condition. The classical presentation involves sudden onset, sharp "tearing" chest pain radiating to the back. However, it can present with a myriad of symptoms, leading to a high occurrence of misdiagnosis and delay in treatment.

METHODS AND RESULTS

A review of the available literature published on AD and diagnostic delays. A systematic review of the literature performed via PubMed and Google scholar using key search terms such as "type A," "aortic dissection," "delay," "misdiagnosis," and synonyms. The Boolean operator used to narrow results specifically to diagnostic elements of AD. A current lack of data collection has impeded the systematic analysis and review of this condition making it difficult to assess reasons for delay. A review of the literature showed a large variation in the presentation of those that have acute AD. Often the presentation mimics other more common conditions such as acute coronary syndrome. Lack of awareness amongst clinicians means that it is often not considered as a differential. Furthermore, the lack of a discriminator for patients being triaged leads to diagnostic delay; this is exacerbated by limited accessibility to diagnostic tests such as CT.

CONCLUSION

Based on the current literature, collaborative data collection, regular audit, national guidance, and communication between Royal Colleges will improve awareness, reduce diagnostic delays, and shine greater light on the issue.

Medikolegale Aspekte des präklinischen Managements von „akuten Aortensyndromen“

Akute Aortensyndrome sind in der Versorgung äußerst zeitkritische Ereignisse, die letztendlich nur in einer hoch spezialisierten medizinischen Einrichtung definitiv versorgt werden können. Um Leben und Gesundheit der Notfallpatienten zu erhalten, steht der schnellstmögliche Transport unter Inanspruchnahme von Sonderrechten mit dem nächsten geeigneten Rettungsmittel im Vordergrund. Die Disposition eines erst später verfügbaren Intensivtransportwagens ist aus medizinrechtlicher Sicht als höchst bedenklich anzusehen.