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Grabert J, Heister U, Mayr A, Fleckenstein T, Kirfel A, Staerk C, Wittmann M, Velten M. Prehospital Misdiagnosed Acute Coronary Syndrome-Incidence, Discriminating Features, and Differential Diagnoses. Rev Cardiovasc Med 2023; 24:75. [PMID: 39077499 PMCID: PMC11263978 DOI: 10.31083/j.rcm2403075] [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: 08/28/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 07/31/2024] Open
Abstract
Background Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the western world. Classic angina pectoris (AP) is a common reason to request prehospital emergency medical services (EMS). Nevertheless, data on diagnostic accuracy and common misdiagnoses are scarce. Therefore, the aim of this study is to evaluate the amount and variety of misdiagnoses and assess discriminating features. Methods For this retrospective cohort study, all patients requiring EMS for suspected ACS in the city of Bonn (Germany) during 2018 were investigated. Prehospital and hospital medical records were reviewed regarding medical history, presenting signs and symptoms, as well as final diagnosis. Results Out of 740 analyzed patients with prehospital suspected ACS, 283 (38.2%) were ultimately diagnosed with ACS (ACS group). Common diagnoses in the cohort with non-confirmed ACS (nACS group) consisted of unspecific pain syndromes, arrhythmias, hypertensive crises, and heart failure. ST segment elevation (adjusted odds-ratios [adj. OR] 2.70), male sex (adj. OR 1.71), T wave changes (adj. OR 1.27), angina pectoris (adj. OR 1.15) as well as syncope (adj. OR 0.63) were identified among others as informative predictors in a multivariable analysis using the lasso technique for data-driven variable selection. Conclusions Misdiagnosed ACS is as common as 61.8% in this cohort and analyses point to a complex of conditions and symptoms (i.e., male sex, electrocardiographic (ECG) changes, AP) for correct ACS diagnosis while neurological symptoms were observed significantly more often in the nACS group (e.g., Glasgow Coma Scale (GCS) < 15, p = 0.03). To ensure adequate and timely therapy for a potentially critical disease as ACS a profound prehospital examination and patient history is indispensable.
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Affiliation(s)
- Josefin Grabert
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Ulrich Heister
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
- Emergency Medical Service Bonn, 53103 Bonn, Germany
| | - Andreas Mayr
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Tobias Fleckenstein
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Andrea Kirfel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Christian Staerk
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Maria Wittmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Markus Velten
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
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Cecchini A, Qureshi MH, Peshin S, Othman A, Gajjar B. Type A Aortic Dissection Presenting as Acute Coronary Syndrome in a Young Male Patient: A Case Report. Cureus 2022; 14:e31578. [DOI: 10.7759/cureus.31578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/17/2022] Open
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Peng H, Liu W, Jian KT, Xia Y, Liu JS, Sun LZ, Mei YQ. Impact of unintentional coronary angiography on outcomes of emergency surgery in acute type A aortic dissection: a retrospective study. BMC Cardiovasc Disord 2022; 22:383. [PMID: 36002794 PMCID: PMC9400216 DOI: 10.1186/s12872-022-02821-4] [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: 03/29/2022] [Accepted: 08/16/2022] [Indexed: 12/02/2022] Open
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02821-4.
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Affiliation(s)
- Hao Peng
- Department of Cardiovascular and Thoracic Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Shanghai, 200065, People's Republic of China.,Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Wei Liu
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Kai-Tao Jian
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Yu Xia
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Jian-Shi Liu
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Shanghai DeltaHealth Hospital, 109 Xule Rd, Shanghai, 201702, People's Republic of China.
| | - Yun-Qing Mei
- Department of Cardiovascular and Thoracic Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Shanghai, 200065, People's Republic of China.
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Llerena J, Nadeem A. Letter to the Editor: Outcomes of preoperative antiplatelet therapy in patients with acute type A aortic dissection. J Card Surg 2022; 37:2227. [PMID: 35245398 DOI: 10.1111/jocs.16375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Jordan Llerena
- Pontificia Universidad Católica del Ecuador, Quito, Ecuador
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Risk Factors for High Blood Product Use in Patients with Stanford Type A Dissection. Thorac Cardiovasc Surg 2022; 70:306-313. [PMID: 35042245 DOI: 10.1055/s-0041-1741004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intraoperative and postoperative bleeding associated with allogeneic blood transfusion and reoperation is still a common and feared complication in patients undergoing surgery due to acute Type A Aortic Dissection (aTAAD). The aim of our study was to identify risk factors for higher transfusion rates. METHODS In this retrospective single center study we evaluated pre -, intra-, and postoperative data of 121 patients with aTAAD. Depending on the median of received packed red blood cells (PRBCs), patients were divided into Group A (<8 PRBC, n = 53) and Group B (≥8 PRBC n = 68). Statistical analyses (descriptive statistics, univariable and multivariable logistic regression) were performed using SPSS software 25.0. Statistical significance was assumed at p-value <0.05. RESULTS A total of 120 patients received a blood product during their perioperative course. Among others we identified age, hemorrhagic pericardial effusion, and dual antiplatelet therapy as preoperative risk factors, low rectal temperature as intraoperative risk factor and low body temperature, positive fluid balance, high lactate level and beginning development of acute renal failure as postoperative risk factors. CONCLUSION Our study identifies several factors which predict a higher likelihood of bleeding and consecutive blood transfusion. Knowledge of these factors could influence the therapy to reduce transfusion requirements and lead to a targeted and more efficient use of coagulation products.
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Zhang B, Wang Y, Guo J, Zhang G, Yang B. Nomogram to differentiate between aortic dissection and non-ST segment elevation acute coronary syndrome: a retrospective cohort study. Cardiovasc Diagn Ther 2021; 11:457-466. [PMID: 33968623 DOI: 10.21037/cdt-20-935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Aortic dissection (AD) and non-ST segment elevation acute coronary syndrome (ACS) are two of the most life-threatening diseases encountered in the emergency department (ED), but there are no rapid and reliable tools for differentiation. The purpose of this study is to develop and validate a nomogram that incorporates both the clinical characteristics and bedside laboratory tests available to differentiate between AD and non-ST segment elevation ACS (NSTE-ACS). Methods Between January 2016 and July 2018, patients with AD and NSTE-ACS were enrolled and divided into training and validation groups. The least absolute shrinkage and selection operator (LASSO) regression model was used to select the factors with significant value of predicting the diagnosis of AD. A nomogram was built on the basis of multivariable logistic regression analysis. Area under the curve (AUC) of receiver operating characteristic (ROC) curve and the calibration curve were used to assess the performance of the nomogram. Decision curve analysis was performed to assess the clinical utility of the nomogram. Results A final cohort of 263 patients (94 patients with AD and 169 patients with NSTE-ACS) were enrolled. Six variables were incorporated in the nomogram: pain severity, tearing pain, pulse asymmetry, electrocardiogram (ECG), D-dimer level and troponin I level. The AUC of the nomogram to predict the probability of AD was 0.919 (95% CI, 0.876-0.962) in the training group and 0.938 (95% CI, 0.888-0.989) in the validation group. The calibration curve demonstrated a good consistency between the actual clinical results and the predicted outcomes. The decision curve analysis indicated that the nomogram had higher overall net benefits in predicting AD in both the training group and the validation group. Conclusions We developed and validated a predictive nomogram that could be used as a tool to differentiate AD from NSTE-ACS rapidly and accurately.
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Affiliation(s)
- Baowei Zhang
- Center of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Cardiology, the affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Yingying Wang
- Department of Cardiology, the affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Junfang Guo
- Department of Cardiology, the affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Guohui Zhang
- Department of Cardiology, the affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Bing Yang
- Center of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Axtell AL, Xue Y, Qu JZ, Zhou Q, Pan J, Cao H, Pan T, Jassar AS, Wang D, Sundt TM, Cameron DE. Type A aortic dissection in the East and West: A comparative study between two hospitals from China and the US. J Card Surg 2020; 35:2168-2174. [PMID: 32652637 DOI: 10.1111/jocs.14766] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In this study, we compare the clinical characteristics, intraoperative management, and postoperative outcomes of patients with acute type A aortic dissection (ATAAD) between two academic medical hospitals in the United States and China. METHODS From January 2011 to December 2017, 641 and 150 patients from Nanjing Drum Tower Hospital (NDTH) and Massachusetts General Hospital (MGH) were enrolled. Patient demographics, clinical features, surgical techniques, and postoperative outcomes were compared. RESULTS The annual number of patients presenting with ATAAD at MGH remained relatively stable, while the number at NDTH increased significantly over the study period. The average age was 51 years at NDTH and 61 years at MGH (P < .001). The percentage of patients with known hypertension at the two centers was similar. The time interval from onset of symptoms to diagnosis was significantly longer at NDTH than MGH (11 vs 3.5 hours; P < .001). Associated complications at presentation were more common at NDTH than MGH. More than 90% of patients (91% NDTH and 92% MGH) underwent surgery. The postoperative stroke rate was higher at MGH (12% vs 4%; P < .001); however, the 30-day mortality rate was lower (7% vs 16%; P = .006). CONCLUSIONS There was a significant increase in the number of ATAAD at NDTH during the study period while the number at MGH remained stable. Hypertension was a common major risk factor; however, the onset of ATAAD at NDTH was nearly one decade earlier than MGH. Chinese patients tended to have more complicated preoperative pathophysiology at presentation and underwent more extensive surgical repair.
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Affiliation(s)
- Andrea L Axtell
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Tuo Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Arminder S Jassar
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Thoralf M Sundt
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Duke E Cameron
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
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