Electrocardiography changes in acute aortic dissection-association with troponin leak, coronary anatomy, and prognosis

Predictive factors for type A aortic dissection mortality based on electrocardiogram parameters and clinical presentations

BACKGROUND

Aortic dissection is a rare but potentially lethal disorder and may be associated with electrocardiogram (ECG) changes. In this study, we aim to investigate ECG-related parameters alongside clinical presentations of type A aortic dissection to come up with the predictive factors for the severity of the disease and its mortality rate.

METHODS

In this retrospective study, 201 patients with type A aortic dissection were studied between March 2015 and March 2020. Two expert cardiologists blinded to the diagnosis studied former and new patients' ECGs and recorded changes.

RESULTS

Two-hundred and one patients, including 143 (71.1%) men and 58 (28.9%) women, presented with acute dissection of the aorta, were studied. Forty-four (21.8%) and 84 (41.7%) patients had ST-segment elevation and depression in ECG, respectively. Bivariate analysis revealed that higher heart rate (p = 0.006), longer QTc (p = 0.044), and ST-segment elevation in aVR lead (p = 0.044) were associated with mortality in the patients. Multivariate regression showed higher heart rate (OR = 1.022, CI = 1.003-1.041, p = 0.012) and ST-segment elevation in aVR (OR = 4.854, CI = 2.255-10.477, p < 0.001) were independently associated with increased odds of mortality in aortic dissection patients. ROC curve analysis showed heart rate equal to or >60 per minute (AUC = 0.625, sensitivity = 86%, specificity = 10%, p = 0.019) and ST-segment elevation in aVR >0.5 mm (AUC = 0.854, sensitivity = 75%, specificity = 92%, p < 0.001) were associated with a higher mortality rate.

CONCLUSION

Heart rate equal or >60 and ST-segment elevation >0.5 mm in aVR lead can be used as predictive factors for mortality of patients with type A aortic dissection.

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.

Elevation Mechanisms and Diagnostic Consideration of Cardiac Troponins under Conditions Not Associated with Myocardial Infarction. Part 2

This article proceeds with a discussion of the causes and mechanisms of an elevation in cardiac troponins in pathological conditions not associated with acute myocardial infarction. The second part of the article discusses the causes and mechanisms of cardiac troponins elevation in diabetes mellitus, arterial hypertension, hereditary cardiomyopathies, cardiac arrhythmias (atrial fibrillation, supraventricular tachycardia), acute aortic dissection, and diseases of the central nervous system (strokes, subarachnoidal hemorrhage). The final chapter of this article discusses in detail the false-positive causes and mechanisms of elevated cardiac troponins.

Total 12-lead QRS voltage in patients with spontaneous acute aortic dissection with an initiating tear in the ascending aorta

Because nearly all patients with acute aortic dissection have systemic hypertension, we examined electrocardiograms (ECGs) in 21 patients with spontaneous acute type A aortic dissection. An earlier study had shown that total 12-lead QRS voltage was the best criterion for determining left ventricular hypertrophy from the ECG. We measured total 12-lead QRS voltage in 21 patients with spontaneous (no previous cardiac or aortic operation) acute type A aortic dissection and operative repair. Using >175 mm as evidence of left ventricular hypertrophy, only 8 patients (38%) had hearts of increased mass. Total 12-lead QRS voltage corresponded slightly with age but not with body mass index. In conclusion, total 12-lead QRS voltage is not useful for diagnostic purposes in patients with acute type A aortic dissection undergoing operative repair.

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.

Painless type A aortic dissection

Aortic dissection is an uncommon diagnosis that typically presents with acute onset of severe pain. It rarely presents with minimal to no symptoms, which carries a higher mortality risk given the delay in diagnosis. An adequate interpretation of risk factors, clinical findings and auxiliary tests constitutes a greater value for clinicians to detect this life-threatening condition. This report describes a case of type A aortic dissection in an asymptomatic patient presenting with an abnormal electrocardiogram (ECG).

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Thoracic Aortic Syndromes

Aortic dissection (AD) is a lethal, treatable disruption of the aortic vessel wall. It often presents without classic features, mimicking symptoms of other conditions, and diagnosis is often delayed. Established high-risk markers of AD should be sought and indicate advanced aortic imaging with CT, MRI, or TEE. Treatment is immediate surgical evaluation, aggressive symptom relief, and reduction of the force of blood against the aortic wall by control of heart rate, followed by blood pressure.