Misdiagnosis of aortic dissection: A systematic review of the literature

Delayed Diagnosis and Outcomes in Acute Aortic Dissection: A 10-Year Single-Center Retrospective Study

Introduction

Acute aortic dissection is a rare and life-threatening condition with highly variable clinical presentations, often resulting in atypical symptoms and initial misdiagnosis. This study aimed to investigate clinical presentations and explore the associations between clinical characteristics, delayed diagnosis, and in-hospital mortality among patients with acute aortic dissection.

Methods

A retrospective chart review was performed on patients presenting with acute aortic dissection at an urban academic emergency department in Thailand between January 1, 2011, and December 31, 2020. Baseline characteristics, clinical presentations, imaging findings, delayed diagnosis (>4 h from first emergency department contact), and in-hospital mortality rates were analyzed.

Results

The study included 103 patient charts, predominately men (71 patients), with a median age of 71 years (interquartile range of 58-78 years). Abdominal pain (36.9%) and thoracic pain (24.3%) were the most common presenting symptoms. Dyspnea (11.7%), altered consciousness (4.9%), and syncope (4.9%) were the three main painless presenting atypical symptoms. Atypical presentations were not significantly associated with delayed diagnosis, which occurred in 27.2% of cases. Normotension, a history of coronary artery disease, and pleural effusion were associated with delayed diagnosis. Abnormal chest films were major risk factors for in-hospital mortality, observed in 22.3% of patients with acute aortic dissection, whereas delayed diagnosis was not directly related to such mortality.

Conclusion

The incidence of acute aortic dissection in the urban Thai population was 32.4 per 100,000 patient-years, with a range of clinical presentations. A high index of suspicion for AAD is crucial for timely diagnosis, even in patients with atypical symptoms and seemingly normal vital signs. Careful interpretation of chest radiographs is essential as abnormal chest X-ray findings are associated with a poorer prognosis.

Ultrasound of the Aorta

This article reviews the use of point-of-care ultrasound (POCUS) for evaluating the aorta from anatomy and image acquisition to the diagnosis of aortic pathology, including aneurysms and dissection. Ruptured aortic aneurysm and aortic dissection are associated with high mortality and often experience a delay in time to diagnosis. Traditionally diagnosis was made through computed tomography which takes time and removes the patient from the emergency department. Incorporating POCUS into the evaluation of patients with suspected aortic pathology allows for rapid, accurate diagnosis and earlier definitive treatment.

Emergency Department Triage Accuracy and Delays in Care for High-Risk Conditions

Importance

Emergency department (ED) triage may impact timeliness of care for high-risk conditions.

Objective

To determine the association of ED undertriage with delays in care for patients with subarachnoid hemorrhage (SAH), aortic dissection (AD), and ST-elevation myocardial infarction (STEMI).

Design, Setting, and Participants

This retrospective cohort study included adult ED patients diagnosed with SAH, AD, or STEMI from January 1, 2016, to December 31, 2020, from a multicenter, community-based health care delivery system. Data analysis were completed in March 2023 to October 2024.

Exposure

Undertriage vs correct triage, defined by operational measures of mistriage.

Main Outcomes and Measures

Using a lognormal distribution, the outcomes of interest for patients with SAH and AD were adjusted median time to noncontrast computed tomography (CT) (head CT for patients with SAH, chest CT for patients with AD), antihypertensive medication orders (SAH), and β-blocker orders (AD), and ED length of stay (LOS). For patients with STEMI, outcomes of interest were adjusted median time to electrocardiogram (ECG) and troponin orders.

Results

A total of 5929 patients (median [IQR] age, 63.0 [54.0 to 73.0] years; 3876 [65.4%] male) were identified, including 915 with SAH, 480 with AD, and 4534 with STEMI. There were 1129 Asian patients (19.0%), 553 Black patients (9.3%), 889 Hispanic patients (15.0%), and 2906 non-Hispanic White patients (49.0%). Overall, 2175 patients (36.7%) were undertriaged. For patients with SAH, the lognormal estimate for delay in time to head CT was 0.2 (95% CI, 0.0-0.3), or a delay of 2.4 minutes, and for antihypertensive orders, the lognormal estimate was 4.8 (95% CI, 3.6-5.9), or a delay of 33.3 minutes; the lognormal estimate for ED LOS was 0.1 (95% CI, 0.0-0.1), or 7.7 minutes longer. For patients with AD, the lognormal estimate for delays were 0.2 (95% CI, 0.0-0.4), or 8.9 minutes, for chest CT and 0.5 (95% CI, 0.2-0.7), or 17.6 minutes, for β-blocker orders, and ED LOS was 0.2 (95% CI, 0.1-0.3), or 64 minutes longer. For patients with STEMI, differences in time to ECG and troponin orders were not statistically significant, at less than 1 minute, comparing correctly and undertriaged patients.

Conclusions and Relevance

In this cohort study of patients diagnosed with SAH, AD, or STEMI, ED undertriage was associated with small but significant delays in key diagnostic and therapeutic orders for patients with SAH and AD but not for patients with STEMI.

Related factors affecting misdiagnosis of aortic dissection: a single-center retrospective study

Objective

Aortic dissection (AD) is a life-threatening cardiovascular emergency. Delayed diagnosis frequently leads to treatment delays, elevated mortality, and complications. This study investigates the factors contributing to the misdiagnosis of AD and proposes strategies for improving its early diagnosis.

Methods

A retrospective analysis of 801 patients with AD identified 219 cases for inclusion, which were split into a training set (131 cases) and a validation set (88 cases). A binary logistic regression model was used to identify factors influencing misdiagnosis, while a Nomogram prediction model was developed.

Results

The analysis revealed that factors such as the timing and suddenness of symptom onset, typical back pain, walk-in clinic visits, and laboratory results (D-dimer, fibrinogen, and white blood count) were significant in predicting misdiagnosis. The Nomogram model showed high predictive accuracy with an Area under the ROC curve (AUC) of 0.924 in the training set and 0.912 in the validation set, demonstrating good sensitivity and specificity.

Conclusion

The model offers potential for improving diagnostic accuracy and clinical outcomes in AD cases.

Performance and costs of rule-out protocols for acute aortic syndromes: analysis of pooled prospective cohorts

BACKGROUND

Acute aortic syndromes (AAS) are deadly conditions causing unspecific symptoms, such as chest/abdominal/back pain, syncope and neurological deficit. They are diagnosed with computed tomography angiography (CTA), but the patient selection is challenging. To support physicians and standardize management, protocols combining a clinical score with D-dimer (DD) have been developed. However, direct comparison of their diagnostic performance and cost-effectiveness is lacking.

METHODS

We used individual patient data from 3 prospective diagnostic studies of patients with suspected AAS, enrolled in 12 centers from 5 countries. Diagnostic accuracy, failure rate and costs were calculated for 5 protocols, applying 3 scores (aortic dissection detection [ADD], AORTAs and Canadian) and 2 DD thresholds (500 ng/mL [DD500], age-adjusted [DDage]). Costs were estimated using Italian and German reimbursements.

RESULTS

Among 4907 patients, 506 (10.3 %) had an AAS. The sensitivity of the diagnostic protocols ranged from 97.6 % for Canadian/DD500 to 99.4 % for AORTAs/DD500 or DDage (P = 0.022). The specificity was lowest for AORTAs/DD500 (46.8 %; P < 0.001 vs AORTAs/DD500) and highest for ADD/DDage (61.5 %; P < 0.001). The number of potential AAS misses was 4-fold higher with Canadian/DD500 vs AORTAs/DD500 or DDage. The net clinical benefit was highest for ADD/DDage. All protocols reduced CTA exams and costs over a CTA-to-all strategy. Numbers of predicted CTA exams and costs per 100 patients were lowest for ADD/DDage (447 CTAs, 34,366 EUR) and highest (579 CTAs, 43,628 EUR) for AORTAs/DD500.

CONCLUSIONS

Guideline-compliant clinical score/DD based protocols are highly sensitive. Differences in specificity and efficiency are present. Data may guide decision-making based on policies and resources.

The Effect of Sepsis Recognition on Telemedicine Use in Rural Emergency Department Sepsis Treatment

Background: Provider-to-provider emergency department telehealth (tele-ED) has been proposed to improve rural sepsis care. The objective of this study was to measure the association between sepsis documentation and tele-ED use, treatment guideline adherence, and mortality. Methods: This analysis was a multicenter (n = 23) cohort study of sepsis patients treated in rural emergency departments (EDs) that participated in a tele-ED network between August 2016 and June 2019. The primary outcome was whether sepsis was documented explicitly in the clinical note impression in the local ED, and the primary exposure was rural tele-ED use, with secondary outcomes of time to tele-ED use, 3-h guideline adherence, and in-hospital mortality. Results: Data from 1,146 rural sepsis patients were included, 315 (27%) had tele-ED used and 415 (36%) had sepsis recognized in the rural ED. Tele-ED use was not independently associated with sepsis recognition (adjusted odds ratio [aOR]: 1.23, 95% confidence interval [CI]: 0.90-1.67). Sepsis recognition was associated with earlier tele-ED activation (adjusted hazard ratio 1.66, 95% CI: 1.28-2.15) and greater 3-h guideline adherence (aOR 1.37, 95% CI 1.03-1.83) Sepsis recognition was not independently associated with mortality (aOR 1.32, 95% CI 0.97-1.80). Conclusions: Although tele-ED care is a promising strategy to improve sepsis outcomes, its use was limited by under-recognition of sepsis in rural EDs.

Can ChatGPT 4.0 Diagnose Acute Aortic Dissection? Integrating Artificial Intelligence into Medical Diagnostics

Acute aortic dissection (AD) is a critical condition characterized by high mortality and frequent misdiagnoses, primarily due to symptom overlap with other medical pathologies. This study explores the diagnostic utility of ChatGPT 4.0, an artificial intelligence model developed by OpenAI, in identifying acute AD from patients' presentations and general physical examination findings documented in published case reports. A systematic search was conducted on the PubMed database using the search term "acute aortic dissection," applying filters for articles published within the past year and categorized as case reports. The primary symptoms and physical examination details from each case were inputted into ChatGPT 4.0, which was prompted to generate three differential diagnoses and one main provisional diagnosis based on the case presentation. The search yielded a total of 163 results, from which 10 case reports were randomly selected. The patient demographics across all 10 case reports demonstrated an age range of 29 to 82 years, with equal gender distribution (5 males, 5 females) and hypertension as the most prevalent baseline comorbidity. ChatGPT 4.0 accurately identified acute AD as one of the top three differential diagnoses in all selected cases and identified acute AD as the provisional diagnosis in five of the 10 cases. In conclusion, while ChatGPT 4.0 demonstrates potential in suggesting acute AD as a differential diagnosis based on clinical data, its role should be considered supportive rather than definitive. Based on our findings, it could serve as an early, cost-effective, and quick screening tool, helping physicians adopt a "think aorta" approach.

Outcomes of Surgical Versus Conservative Management in Stanford Type a Aortic Dissection: A Single-Center Retrospective Study

Acute aortic dissection (AAD) is a critical cardiovascular emergency marked by the rupture of the aortic intima, resulting in blood infiltration into the media and the formation of a false lumen. AAD incidence varies by area, emphasizing the need for better diagnostics and epidemiological investigations. Bucharest University Emergency Hospital's Emergency Department conducted this retrospective cohort analysis from May 2021 to May 2023. We examined 26 Stanford Type A aortic dissection patients to establish in-hospital mortality and one-year survival rates. The primary objective was to analyze demographic, clinical, and paraclinical factors and their impact on patient outcomes. A total of 57.7% of the study group was male and had a mean age of 58.2 years, and 69.2% of patients had hypertension, indicating its importance as a risk factor. Acute chest discomfort was reported by 53.8%, neurological problems by 30.8%, and syncope or hypotension by 42.3%. CT angiography and transthoracic echocardiogram (TTE) confirmed the diagnosis and assessed dissection severity. Pericardial effusion (19.2%) and moderate to severe aortic regurgitation (26.9%) were notable. Management varied by dissection intensity and location. Emergency surgery was performed in 61.5% of patients within 24 h of diagnosis, resulting in a 12.5% in-hospital death rate. Conservatively managed patients had a 60.0% in-hospital death rate. Timely intervention is crucial, since the surgical cohort had an 87.5% one-year survival rate compared to 30% for the conservatively managed cohort. Acute renal damage (25%), protracted mechanical ventilation (31.3%), and advanced supportive care infections were postoperative sequelae. Conservative care exacerbated visceral ischemia (20%) and heart failure (10%). Advanced age and hypotension upon admission were independent mortality predictors, emphasizing the need for early risk assessment and personalized treatment. Multimodal imaging, timely surgical referral, and excellent postoperative care improve AAD outcomes, according to this study.

Hypertension self-management trajectory patterns and associated factors among Chinese patients with aortic dissection after surgical repair: a longitudinal study

AIMS

In patients with aortic dissection (AD) after surgical repair, especially those with hypertension, better management of blood pressure is associated with better health outcomes. The aim of this study is to identify hypertension self-management trajectory patterns and associated factors among Chinese aortic dissection patients after surgical repair to assist in developing tailored behavioural interventions for this population.

METHODS AND RESULTS

178 patients with aortic dissection who underwent surgical repair were followed for 3 months. Data on hypertension self-management, hypertension knowledge, self-efficacy, and social support were collected before discharge and at 1 and 3 months after discharge. Sociodemographic and clinical data were also collected. A latent class growth model and generalized estimating equations were used to explore hypertension self-management trajectory patterns and factors associated with each pattern. The participants' average age was 57.95 (± 11.27) years. Two hypertension self-management trajectory patterns were identified: 'rapid ascent then suppressed growth' (93.4%) and 'continuously slow ascent' (6.6%). For the 'rapid ascent then suppressed growth' pattern, age, educational background, type of health insurance, family monthly income, self-efficacy, and social support were associated with this pattern (P < 0.05).

CONCLUSION

Healthcare providers may prioritize hypertension self-management for patients who are younger, have lower educational levels, have resident or employee medical insurance and have a family monthly income between 5001 and 10 000 yuan. Self-efficacy and social support might serve as targets for future intervention to improve hypertension self-management.

REGISTRATION

ChiCTR2100050542.

A Narrative Review of Biomarkers and Imaging in the Diagnosis of Acute Aortic Syndrome

Acute aortic syndrome (AAS) encompasses a range of life-threatening conditions, including classical dissection, intramural hematoma, and penetrating aortic ulcer. Each of these conditions presents distinct clinical characteristics and carries the potential to progress to rupture. Because AAS can be asymptomatic or present with diverse symptoms, its diagnosis requires clinical evaluation, risk scoring, and biomarkers such as D-dimer (DD), C-reactive protein (CRP), homocysteine, natriuretic peptides (BNP), and imaging modalities like computed tomography (CT), magnetic resonance imaging (MRI), and echocardiography. While this review primarily focuses on widely used and clinically accessible biomarkers and imaging techniques, it also discusses alternative biomarkers proposed for diagnostic use. Although CT remains the gold standard for diagnosis, biomarkers facilitate rapid risk stratification, complementing imaging techniques. Emerging technologies, such as metabolomics, are reshaping diagnostic algorithms. Despite advances in diagnostic methods, challenges such as misdiagnosis and missed diagnoses persist. Ongoing research into novel biomarkers and innovative imaging techniques holds promise for improving diagnostic accuracy and patient outcomes.

Clinical manifestations and misdiagnosis factors of pulmonary embolism patients seeking treatment in cardiology

To explore the clinical manifestations and factors leading to misdiagnosis in pulmonary embolism (PE) patients in a cardiology department. We retrospectively analyzed 74 patients diagnosed with PE at our hospital from March 2018 to March 2022, comparing them to 136 patients suspected of PE but excluded by computed tomography pulmonary angiography during the same period. Both groups received the same basic care, including disease counseling, nutritional planning, and monitoring. We compared general information, clinical manifestations, risk factors, and auxiliary examinations to identify correlations between specific manifestations and misdiagnosis factors. The male-to-female ratio in the PE group was approximately 3:4, which was statistically significant compared to the control group (P < .05), though its impact on PE incidence was low. Common symptoms in the PE group included chest tightness, shortness of breath, sweating, and chest pain, with no significant difference from the control group (P > .05). Notable risk factors included deep vein thrombosis (DVT) (43.24%), prolonged bed rest (32.43%), lower limb varicose veins (18.92%), trauma (21.62%), pulmonary infections (62.16%), coronary heart disease (37.84%), respiratory failure (32.43%), and chronic obstructive pulmonary disease (13.51%). DVT was significantly associated with PE (P < .05). Multivariate logistic regression identified DVT (OR = 118.528, 95% CI: 6.959-2018.906, P = .001) and lower limb varicose veins (OR = 212.766, 95% CI: 6.584-6875.950, P = .003) as independent predictive factors for suspected PE. Clinical manifestations strongly correlated with PE included pulmonary rales, cyanosis, tachycardia, hypotension, elevated D-dimer, positive N-terminal pro-brain natriuretic peptide, and sinus tachycardia on echocardiogram. PE in cardiology patients may present with pulmonary rales, hypotension, shortness of breath, and abdominal symptoms, warranting reexamination for PE. Misdiagnosis factors typically involve chest pain, tightness, and shortness of breath. Lower limb varicose veins and DVT are reliable predictors of suspected PE.

Ventricular fibrillation arrest in aortic dissection presenting as myocardial injury

An acute aortic dissection can be a tremendously fatal vascular condition if not managed promptly. However, the symptom profile of aortic dissections can be ambiguous to numerous conditions which are more common and greater pursued by clinicians before suspicion of dissection is made. The case presented in this study is of a 61-year-old male who arrives to the emergency department for concern of new-onset chest pain which progresses into ventricular fibrillation arrest prior to diagnosis of aortic dissection. This case report profiles the mimicking possibility of aortic dissection to present as acute myocardial injury, and the utility of models use to differentiate the workup between aortic dissections and acute coronary syndromes.

Exploratory analysis of Type B Aortic Dissection (TBAD) segmentation in 2D CTA images using various kernels

Type-B Aortic Dissection is a rare but fatal cardiovascular disease characterized by a tear in the inner layer of the aorta, affecting 3.5 per 100,000 individuals annually. In this work, we explore the feasibility of leveraging two-dimensional Convolutional Neural Network (CNN) models to perform accurate slice-by-slice segmentation of true lumen, false lumen and false lumen thrombus in Computed Tomography Angiography images. The study performed an exploratory analysis of three 2D U-Net models: the baseline 2D U-Net, a variant of U-Net with atrous convolutions, and a U-Net with a custom layer featuring a position-oriented, partially shared weighting scheme kernel. These models were trained and benchmarked against a state-of-the-art baseline 3D U-Net model. Overall, our U-Net with the VGG19 encoder architecture achieved the best performance score among all other models, with a mean Dice score of 80.48% and an IoU score of 72.93%. The segmentation results were also compared with the Segment Anything Model (SAM) and the UniverSeg models. Our findings indicate that our 2D U-Net models excel in false lumen and true lumen segmentation accuracy while achieving lower false lumen thrombus segmentation accuracy compared to the state-of-the-art 3D U-Net model. The study findings highlight the complexities involved in developing segmentation models, especially for cardiovascular medical images, and emphasize the importance of developing lightweight models for real-time decision-making to improve overall patient care.

Bedside-focused transthoracic echocardiography in acute atraumatic thoracic aortic syndrome: a systematic review and meta-analysis of diagnostic accuracy

The objective of this review was to assess the diagnostic accuracy of bedside-focused transthoracic echocardiography (TTE) in acute atraumatic thoracic aortic syndrome in adults. We performed a systematic review and meta-analysis of publications that described the use of bedside-focused TTE on adults presenting to emergency care settings with suspected atraumatic thoracic aortic syndrome. Studies were identified using keyword and MeSH on relevant databases as well as grey literature, followed by abstract screening and study selection by two independent reviewers. Sixteen studies over six decades were included in the meta-analysis ( n  = 4569 patients). The prevalence of type A thoracic aortic dissection was 11% (range 1.4-45.7%) and type B dissection was 7% (range 1.8-30.55%). Pooled sensitivity and specificity for type A dissection (through direct TTE visualisation of an intimal flap) were 89% [95% confidence interval (CI), 82-94%] and 92% (95% CI, 88-95%), respectively. For type B dissection, pooled sensitivity was 65% (95% CI, 45-80%) and specificity was 100% (95% CI, 0.69-100%). Regarding indirect TTE signs, pooled sensitivities and specificities were 64% (5.2-98.2%) and 94% (92-96.1%), respectively for aortic valve regurgitation, 92% (54-99.2%) and 87% (62-97%) for thoracic aortic aneurysm and 39% (33.8-45%) and 94% (92-95%) for pericardial effusion. In this systematic review and meta-analysis, bedside-focused TTE has high specificity for type A and B dissection, a moderate to high sensitivity for type A but poor for type B, and unclear diagnostic accuracy for intramural haematoma and penetrating aortic ulcer.

Ultrasound of the Aorta

This article reviews the use of point-of-care ultrasound (POCUS) for evaluating the aorta from anatomy and image acquisition to the diagnosis of aortic pathology, including aneurysms and dissection. Ruptured aortic aneurysm and aortic dissection are associated with high mortality and often experience a delay in time to diagnosis. Traditionally diagnosis was made through computed tomography which takes time and removes the patient from the emergency department. Incorporating POCUS into the evaluation of patients with suspected aortic pathology allows for rapid, accurate diagnosis and earlier definitive treatment.

Diagnostic Performance of a Deep Learning-Powered Application for Aortic Dissection Triage Prioritization and Classification

This multicenter retrospective study evaluated the diagnostic performance of a deep learning (DL)-based application for detecting, classifying, and highlighting suspected aortic dissections (ADs) on chest and thoraco-abdominal CT angiography (CTA) scans. CTA scans from over 200 U.S. and European cities acquired on 52 scanner models from six manufacturers were retrospectively collected and processed by CINA-CHEST (AD) (Avicenna.AI, La Ciotat, France) device. The diagnostic performance of the device was compared with the ground truth established by the majority agreement of three U.S. board-certified radiologists. Furthermore, the DL algorithm's time to notification was evaluated to demonstrate clinical effectiveness. The study included 1303 CTAs (mean age 58.8 ± 16.4 years old, 46.7% male, 10.5% positive). The device demonstrated a sensitivity of 94.2% [95% CI: 88.8-97.5%] and a specificity of 97.3% [95% CI: 96.2-98.1%]. The application classified positive cases by the AD type with an accuracy of 99.5% [95% CI: 98.9-99.8%] for type A and 97.5 [95% CI: 96.4-98.3%] for type B. The application did not miss any type A cases. The device flagged 32 cases incorrectly, primarily due to acquisition artefacts and aortic pathologies mimicking AD. The mean time to process and notify of potential AD cases was 27.9 ± 8.7 s. This deep learning-based application demonstrated a strong performance in detecting and classifying aortic dissection cases, potentially enabling faster triage of these urgent cases in clinical settings.

Early Diagnosis of an Atypical Type A Aortic Dissection With Point-of-Care Ultrasound: A Case Report

Aortic dissection is a rare but potentially fatal condition, characterized by a high mortality rate where every minute of delay in treatment counts. Its diagnosis remains challenging due to its often atypical clinical presentation. This case report presents an atypical case of type A aortic dissection in a 75-year-old female patient, highlighting the importance of early diagnosis facilitated by point-of-care ultrasound and emphasizing the value of its use in suspected aortic dissection regardless of the clinical probability. Additionally, this report reviews the risk factors for misdiagnosis and underscores the utility of diagnostic scores such as the aortic dissection detection risk score.

The wolf in sheep's clothing: vasovagal syncope in acute aortic dissection

BACKGROUND

The presentation of acute aortic dissection can pose a challenge for emergency physicians, as it may occur without pain. Atypical presentations can lead to significant delays in diagnosis and increased mortality rates.

CASE DESCRIPTION

Our case illustrates that isolated painless syncope can be a rare presenting symptom of acute aortic dissection type A. What is unique about our case is the limited extension of the dissection tear and the availability of Holter monitoring during the syncopal episode.

CONCLUSION

This constellation provides insight into the pathophysiological mechanism of the syncope in this patient. Mechanisms of syncope related to acute aortic dissection are diverse. We show that vasovagal activation not related to pain can be the underlying mechanism of syncope in acute aortic dissection type A. Although excessive vasovagal tone in the setting of aortic dissection has been hypothesized in the past, it has never been as clearly illustrated as in the present case. This also highlights the challenge in risk stratification of syncope in the emergency department.

Concealed Truths Always Hide behind the Shadows of the Not So Obvious: Deadly Chest Pain Presentation

Acute aortic dissection (AAD) is a critical condition characterized by the tearing of the aortic wall, posing significant diagnostic challenges due to its diverse clinical presentations. We present the case of a 61-year-old male with hypertension and dyslipidemia who presented with acute abdominal and chest pain, initially raising suspicion of myocardial infarction. Despite an unremarkable electrocardiogram and initially normal troponin levels, the patient experienced ventricular fibrillation, prompting further evaluation. The patient's clinical course was complicated by recurrent cardiac arrests. Subsequent imaging revealed AAD, which was not initially recognized, emphasizing the importance of maintaining a broad differential diagnosis and the critical need for prompt recognition and management of AAD. This case underscores the necessity of considering AAD in patients with atypical presentations and the pivotal role of advanced imaging techniques in facilitating timely diagnosis and appropriate intervention.

The combined use of serum Raman spectroscopy and D dimer testing for the early diagnosis of acute aortic dissection

Objectives

Acute aortic dissection (AAD) is an extremely life-threatening medical emergency, often misdiagnosed in its early stages, resulting in prolonged wait times for rescue. This study aims to identify potential serum biomarkers that can assist in the accurate diagnosis of AAD and effectively differentiate it from other conditions causing severe chest pain.

Methods

A total of 122 patients with AAD and 129 patients with other severe chest pain disorders were included in the study. Serum samples were analyzed by measuring the peak intensities of Raman spectra. For each measurement, the Raman spectrum was accumulated by two accumulations (3 s per acquisition). Logistic regression and nomogram models were developed using these peak intensities as well as D-dimer levels to predict the occurrence of AAD. The clinical utilities of these models were assessed through receiver operating characteristics (ROC) curve analysis, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA) in both training and internal test cohorts.

Results

The D-dimer levels of AAD patients were significantly increased, as well as higher intensities at specific Raman peaks, including 505 cm-1, 842 cm-1, 947 cm-1, 1254 cm-1, 1448 cm-1, and 1655 cm-1 when compared to non-AAD patients. Conversely, decreased intensities were observed at Raman peaks such as 750 cm-1, 1004 cm-1, 1153 cm-1, 1208 cm-1, and 1514 cm-1 in AAD patients. Least absolute shrinkage and selection operator regression analysis on the training cohort identified eight potential predictors: D-dimer along with intensity measurements at peaks such as 505 cm-1, 750 cm-1, 1153 cm-1, 1208 cm-1, 1254 cm-1, 1448 cm-1, and 1655 cm-1. The combination of these eight potential predictors demonstrated a good discriminatory performance, with an area under the curve (AUC) value of 0.928 in the training cohort and an AUC of 0.936 in the internal test cohort, outperforming the use of D-dimer alone. Furthermore, DCA curve analysis revealed that leveraging this combination of eight potential predictors would provide substantial net benefits for clinical application. Moreover, this combination significantly augmented discrimination power, as evidenced by a continuous NRI of 39.8 % and IDI of 9.95 % in the training cohort, as well as a continuous NRI of 27.1 % and IDI of 9.95 % in the internal test cohort.

Conclusions

The employment of this combination of eight potential predictors effectively rules out AAD to a greater extent. This study presents a promising diagnostic strategy for early detection using optical diagnostic techniques such as Raman spectroscopy.

Quantitative Detection of Multiple Cardiovascular Biomarkers by an Antibody Microarray-Based Metal-Enhanced Fluorescence Assay

Accurate detection of multiple cardiovascular biomarkers is crucial for the timely screening of acute coronary syndrome (ACS) and differential diagnosis from acute aortic syndrome (AAS). Herein, an antibody microarray-based metal-enhanced fluorescence assay (AMMEFA) has been developed to quantitatively detect 7 cardiovascular biomarkers through the formation of a sandwich immunoassay on the poly(glycidyl methacrylate-co-2-hydroxyethyl methacrylate)-decorated GNR-modified slide (GNR@P(GMA-HEMA) slide). The AMMEFA exhibits high specificity and sensitivity, the linear ranges span 5 orders of magnitude, and the limits of detection (LODs) of cardiac troponin I (cTnI), heart-type fatty acid binding protein (H-FABP), C-reactive protein (CRP), copeptin, myoglobin, D-Dimer, and N-terminal pro-brain natriuretic peptide (NT-proBNP) reach 0.07, 0.2, 65.7, 0.6, 0.2, 8.3, and 0.3 pg mL-1, respectively. To demonstrate its practicability, the AMMEFA has been applied to quantitatively analyze 7 cardiovascular biomarkers in 140 clinical plasma samples. In addition, the expression levels of cardiovascular biomarkers were analyzed by the least absolute shrinkage and selector operator (LASSO) regression, and the area under receiver operator characteristic curves (AUCs) of healthy donors (HDs), ACS patients, and AAS patients are 0.99, 0.98, and 0.97, respectively.

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.

Diagnosis and management of acute aortic dissection in the emergency department

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.

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

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.

Type B Aortic Dissection Masquerading As Acute Pyelonephritis: Think Beyond Measures

Aortic dissection (AD) is a life-threatening medical emergency with a high mortality rate if misdiagnosed; therefore, an urgent and precise diagnosis is crucial for prompt treatment. This article presents a rare case report of AD with an atypical clinical presentation that led to delayed diagnosis and a complicated clinical course. Herein, we aim to contribute to the existing literature by providing insights into the varied presentations of AD and offering valuable lessons for clinicians faced with similar diagnostic scenarios. A 64-year-old female with an extended history of hypertension and other comorbidities presented to the emergency department with a one-day duration of right-sided loin pain and fever. Her blood investigations demonstrated evidence of leukocytosis and high c-reactive protein (CRP) levels. She was preliminarily treated as a case of acute pyelonephritis since, initially, clinical and radiographic evidence did not yield an alternative diagnosis. Despite antibiotics, her condition deteriorated, and her urine output became less than 0.5 mL/kg/hour for six consecutive hours. Additionally, the obtained urine culture was negative on the third day of admission, which made the medical team repeat her history taking and clinical examination, revealing a previously overlooked weight loss. This red flag prompted the medical team to conduct thorough chest and abdominal imaging studies in search of any hidden malignancy, especially when her thyroid function test returned normal. Surprisingly, a contrast-enhanced abdominal CT scan demonstrated an infarcted right kidney by thromboembolism that originated from the partially obstructive thrombus in the proximal abdominal aorta, which was later confirmed to be a type B AD by a CT angiogram. A multidisciplinary team guided her treatment, which included carefully controlling her blood pressure, using anticoagulants, and closely monitoring the patient. The take-home messages of this case report underscore the critical importance of recognizing atypical clinical presentations of AD, overcoming diagnostic challenges through comprehensive approaches, tailoring treatments to individual patient needs, and advocating for a multidisciplinary and patient-centered approach to enhance overall clinical outcomes.

Three cases of diagnostic delay of type A acute aortic dissection

BACKGROUND

Diagnostic delay (DD) can be lethal when patients with type A acute aortic dissection (TAAAD). We report 3 cases of DD associated with TAAAD.

CASE PRESENTATION

Case 1 is a female in her sixties presenting with severe back pain. A CT scan was taken, and TAAAD with a thrombosed false lumen was suspected by the radiology technician. He did not successfully transfer his concern to the physicians and the patient was sent home. The next day, she was transferred to another hospital with a recurrence of the symptom, and the diagnosis of TAAAD was made with a CT scan there. Case 2 was an 87-year-old female who was transferred to our hospital because of a loss of consciousness and bruises on the forehead. CT scan was taken and the displaced intimal flap in her aortic arch was overlooked by the part-time physician almost at the end of his shift. The diagnosis of TAAAD was made by the radiologist. Case 3 was the 44-year-old male who did not have health insurance and experienced severe back pain a few days before the visit to our clinic. On that day, he went to the nearby hospital's emergency room, and only pain medication was prescribed. A few days later, a CT scan was taken at our hospital to investigate the cause of pyuria and the diagnosis of TAAAD was made.

CONCLUSION

DD may be common and multifactorial in our practice. Physicians need to take every step to improve diagnostic accuracy.

Current understanding of the genetics of thoracic aortic disease

Thoracic aortic dissection is a feared, highly lethal condition most commonly developing from aneurysmal dilation of the thoracic aorta. Elective prophylactic replacement of thoracic aortic aneurysms dramatically mitigates this risk. However, diagnosis of a thoracic aortic aneurysm can be challenging. Thoracic aortic disease - horacic aortic aneurysm and dissection (TAAD) - can be sporadic or heritable. Patients with syndromic heritable TAAD present with classic phenotype and clinical features correlating to their disease. In contrast, patients with non-syndromic heritable disease are harder to diagnose due to their lack of defining uniform phenotypes. Recent advances in genomics have begun to elucidate the genetic underpinnings of non-syndromic TAAD (ns-TAAD) for better understanding this complex disease and improve diagnosis and management. Herein, we review the foundation of knowledge in ns-TAAD heritability and key research studies identifying gene mutations in vascular smooth muscle cells, the extracellular matrix, and TGF-beta signaling present in ns-TAAD. We summarize the current guidelines for the diagnosis, screening, and surgical management of ns-TAAD including recommendations for genetic testing of high-risk individuals. Finally, we highlight areas of future research that will continue to advance our understanding of the complex genetic and epigenetic factors in TAAD.

Spontaneous Extensive Type A Aortic Dissection in an Older Female with No Risk Factors: A Rare Clinical Presentation

Background

Aortic dissection (AD) is a rare but serious medical emergency where the aorta's inner layer tears. Females are less likely to develop it than males, and AD cases with unusual symptoms can be hard to diagnose. Diagnosing AD can be further complicated as its symptoms and electrocardiogram (ECG) changes can mimic acute coronary syndrome, and it is challenging to distinguish it without risk factors. Case Report. This case report describes a 60-year-old female patient who presented with unusual symptoms, including pain in her chest, neck, left arm, and lower extremities. An electrocardiogram (ECG) revealed ST elevation in leads aVR and V1, as well as severe ST depression and T wave inversion in the inferior and lateral leads, which can mimic acute coronary syndrome. Despite initial treatment with nitroglycerin, the patient's pain worsened, and a CT angiography revealed type A aortic dissection extending from the aortic root to the right external iliac artery. Immediate surgery was recommended, which significantly improved the patient's condition.

Conclusions

Be aware of aortic dissection and its symptoms, even if there are no risk factors or recognizable symptoms. Consider aortic dissection as a potential diagnosis if ECG changes are present. Ongoing education can help decrease mortality and increase awareness.

A Novel Tool for Distinguishing Type A Acute Aortic Syndrome from Heart Failure and Acute Coronary Syndrome

Type A acute aortic syndrome (urgent AAS, UAAS) has a low incidence and high mortality rate; however, it is often missed or diagnosed late. Our aim was to create a new tool for distinguishing UAAS by using multiple modalities to select patients for CT aortography. This study included 75 patients with UAAS, 77 with acute coronary syndrome (ACS), and 81 with heart failure (HF) who received urgent treatment after propensity matching. Specific symptoms, past medical history, mediastinal width, region of interest (ROI) ratio in the lung base/apex, D-dimers, and troponin I were investigated to differentiate UAAS from ACS and HF. The most significant variables were selected to create a new scoring system. The UAAS score exhibited a performance AUC of 0.982. A simple UAAS score >1, excluding ROI ratios in lung base/apex, showed an AUC of 0.977, a sensitivity of 96%, and specificity of 92.41%. The results were validated using an external data set of 292 patients (simple UAAS score > 1: AUC of 0.966, sensitivity 93.33%, and specificity 95.36%). The simple UAAS score may be a valuable tool for suspecting UAAS and may reduce the likelihood of misdiagnosis or performing unnecessary CT aortography.

Metabolomic analysis reveals the metabolic disturbance in aortic dissection: Subtype difference and accurate diagnosis

BACKGROUND AND AIMS

Aortic dissection (AD), a severe clinical emergency with high mortality, is easily misdiagnosed as are other cardiovascular diseases. This study aimed at discovering plasma metabolic markers with the potential to diagnose AD and clarifying the metabolic differences between two subtypes of AD.

METHODS AND RESULTS

To facilitate the diagnosis of AD, we investigated the plasma metabolic profile by metabolomic approach. A total 482 human subjects were enrolled in the study: 80 patients with AD (50 with Stanford type A and 30 with Stanford type B), 198 coronary artery disease (CAD) patients, and 204 healthy individuals. Plasma samples were submitted to targeted metabolomic analysis. The partial least-squares discriminant analysis models were constructed to illustrate clear discrimination of AD patients with CAD patients and healthy control. Subsequently, the metabolites that were clinically relevant to the disturbances in AD were identified. Twenty metabolites induced the separation of AD patients and healthy control, 9 of which caused the separation of CAD patients and healthy control. There are 11 metabolites specifically down-regulated in AD group. Subgroup analysis showed that the levels of glycerol and uridine were dramatically lower in the plasma of patients with Stanford type A AD than those in the healthy control or Stanford type B AD groups.

CONCLUSION

This study characterized metabolomic profiles specifically associated with the pathogenesis and development of AD. The findings of this research may potentially lead to earlier diagnosis and treatment of AD.

Factors Affecting False Lumen Thrombosis In Type B Aortic Dissection

BACKGROUND

Complete thrombosis of the false lumen facilitates remodeling of type B aortic dissection (TBAD). Morphological characteristics affect thrombosis in the false lumen.

OBJECTIVES

Discuss the factors present before admission that influence false lumen thrombosis in patients with TBAD.

METHODS

We studied 282 patients diagnosed with TBAD in our hospital between January 2008 and December 2017. We divided the subjects into a thrombotic group and a non-thrombotic group based on whether any thrombus was detectable in the false lumen. We analyzed the differences between the two groups with respect to clinical data, the vertical length of the dissection, and the diameter of the aorta. P values < 0.05 were considered statistically significantly different.

RESULTS

Significant differences between the thrombotic group and non-thrombotic group were found with respect to age (53.92 ± 11.40 vs. 50.36 ± 10.71, p = 0.009) and proportion of patients with renal insufficiency (7.83% vs. 16.38%, p = 0.026). In zones 3-9, the true lumen diameter of the thrombotic group was significantly larger than in the non-thrombotic group (p < 0.05). Binary logistic regression analysis showed that true lumen diameter in zone 5 and renal insufficiency were independent predictors of false lumen thrombosis.

CONCLUSIONS

Age and renal function were associated with thrombosis in the false lumen. Potentially, the difference between the diameter of the true lumen diameter and that of the false lumen may influence the thrombosis of the false lumen.

A Case of Acute Aortic Dissection Presenting With Neurological Symptoms

Aortic dissection (AD) is a life-threatening condition that presents with diverse and atypical symptoms, making it challenging to diagnose. We present a case of a woman in her 40s who presented to the emergency department with collapse, right-sided weakness, agitation, and confusion. Despite efforts, she went into cardiac arrest and died before a definitive diagnosis was made. The post-mortem examination revealed hemopericardium due to dissection of the ascending thoracic aorta as the cause of death. This case highlights the difficulty in diagnosing AD and the need for a high index of suspicion, especially in patients presenting with neurological symptoms and risk factors.

Factors affecting distal false lumen enlargement after thoracic endovascular aortic repair for type B aortic dissection

Objective

To investigate the factors influencing distal false lumen enlargement after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection.

Materials and methods

Data were collected on patients with type B aortic dissection who underwent TEVAR from January 2008 to August 2022. Patients were divided into a distal aortic segmental enlargement (DSAE) group and a non-DSAE group based on whether the distal false lumen was dilated more than 5 mm on computed tomographic angiography (CTA) images. To analyze the independent influences on distal false lumen dilatation after TEVAR, the variables with a P value < 0.05 during univariate analysis were included in the binary logistic regression analysis model.

Results

A total of 335 patients were included in this study, with 85 in the DSAE group and 250 in the non-DSAE group. The mean age was 52.40 ± 11.34 years, 289 (86.27%) were male patients, and the median follow-up time was 6.41 (11.99-29.99) months. There were significant differences in Marfan syndrome, chronic obstructive pulmonary disease (COPD), and follow-up time between the two groups. In terms of morphology, there were statistically significant differences in the number of tears, the size of the primary tear, and the length of dissection between the two groups. Binary logistic regression analysis indicated that Marfan syndrome, COPD, and the primary tear size were associated with distal false lumen dilatation.

Conclusions

Marfan syndrome, COPD, and the primary tear size influence distal aortic segmental enlargement after TEVAR in type B aortic dissection patients.

A Devastating Tear: Atypical Presentation of Aortic Dissection Discovered on Echocardiography

Acute aortic dissection (AAD) is a serious medical problem that requires prompt recognition in order to prevent deadly complications. Nevertheless, making the diagnosis can often be challenging. The clinical signs and symptoms of AAD may vary depending on the location of the dissection, leading to subtle differences in the initial patient presentation. Moreover, the classically described signs of blood pressure disparity, pulse deficit, or the presence of a diastolic murmur are often absent. Here, we report a challenging case of AAD in which the patient presented with acute substernal chest pain that resolved after a short period and was associated with hypotension. His bilateral upper and lower extremities were well perfused with symmetrical, palpable pulses. The initial point-of-care ultrasound (POCUS) showed a small pericardial effusion, and a follow-up echocardiogram revealed an ascending aortic flap with aortic root dilation diagnostic of AAD. Our aim is to shed light on the challenge of diagnosing AAD.

Acute aortic dissection

Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.

The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies

BACKGROUND

The research of the sensitivity and specificity point-of-care testing (POCT) of D-dimer as a diagnostic protocol for differential diagnosis of Stanford Type A aortic syndrome (hereafter as TAAS) mimicking ST-elevated myocardial infarction (STEMI) with regular STEMI in the emergency department is limited.

METHODS

Full medical information of 32 patients confirmed TAAS and 527 patients confirmed STEMI from January 1st, 2016 to October 1st, 2021 were retrospectively analyzed in Shanghai Tenth People's Hospital of Tongji University.

RESULTS

The baseline characteristics of two groups of patients were well-balanced post propensity score matching (PSM) analysis, and each group had 32 patients enrolled. Patients in the STEMI group had higher positive cardiac troponin I (cTNI) (0.174 ng/ml vs. 0.055 ng/ml, P = 0.008) results but lower D-dimer (0.365μg/ml vs. 31.50μg/ml, P < 0.001) results than the TAAS group. The D-dimer cutoff value of 2.155μg/ml had the best sensitivity of 100% and specificity of 96.9%, and the positive predictive value (PPV) as well as the negative predictive value (NPV) of the cutoff value were 96.9 and 100%, respectively, in total 64 patients, the area under the curve (AUC) values were 0.998 (95% CI:0.992-1.000, P < 0.001) for the D-dimer. No significant correlation between the D-dimer concentration and the time from symptoms onset to first medical contact in both groups (TAAS group: r = - 0.248, P = 0.170; STEMI group: r = - 0.159, P = 0.383) or significant correlation between D-dimer and creatine clearance (TAAS group: r = - 0.065, P = 0.765; STEMI group: r = 0.222, P = 0.221). The total in-hospital mortality for the patients with TAAS presenting as STEMI was 62.5% (20/32). The mortality rate for TAAS patients confirmed by computed tomography angiography (CTA) was significantly lower (40% vs. 82.4%, P = 0.014) than the mortality rate for TAAS patients confirmed by coronary angiography (CAG) and had a longer average survival time (log-rank = 0.015), less peri-surgical complications especially gastrointestinal hemorrhage (0.00% vs. 55.6%, P < 0.001). CTA diagnosis can reduce the mortality rate by 67.5% (95%CI:0.124-0.850, P = 0.16).

CONCLUSIONS

The POCT D-dimer with cut-off 2.155μg/ml would be useful to rule-out TAAS mimicking STEMI from regular STEMI prior to reperfusion therapy. CTA diagnosis is effective in reducing the probability of perioperative complications and lowering perioperative mortality than CAG diagnosis in TAAS patients.

Acute aortic syndromes: An internist's guide to the galaxy

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.

Emerging Role of Non-Coding RNAs in Aortic Dissection

Aortic dissection (AD) is a fatal cardiovascular acute disease with high incidence and mortality, and it seriously threatens patients’ lives and health. The pathogenesis of AD mainly includes vascular inflammation, extracellular matrix degradation, and phenotypic conversion as well as apoptosis of vascular smooth muscle cells (VSMCs); however, its detailed mechanisms are still not fully elucidated. Non-coding RNAs (ncRNAs), including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs), are an emerging class of RNA molecules without protein-coding ability, and they play crucial roles in the progression of many diseases, including AD. A growing number of studies have shown that the dysregulation of ncRNAs contributes to the occurrence and development of AD by modulating the expression of specific target genes or the activity of related proteins. In addition, some ncRNAs exhibit great potential as promising biomarkers and therapeutic targets in AD treatment. In this review, we systematically summarize the recent findings on the underlying mechanism of ncRNA involved in AD regulation and highlight their clinical application as biomarkers and therapeutic targets in AD treatment. The information reviewed here will be of great benefit to the development of ncRNA-based therapeutic strategies for AD patients.

Should Audits Consider the Care Pathway Model? A New Approach to Benchmarking Real-World Activities

Clinical audit is a method to assess the quality of healthcare services based on whether standards are met or not met. This approach is limited because it fails to recognize how decisions that take place over time and the natural progression of disease has an impact on what happens to patients and the care they receive. The aim of this paper is to introduce the concept of care pathway and explain how care pathways can be audited to better understand care. The care pathway is defined by clinically relevant events that take place within one or more healthcare institutions. The process begins with defining an ideal care pathway which is created by considering local expertise and guidelines. It is then possible to audit against the extent to which this ideal care pathway is achieved. This care pathway audit can enable identification of patterns in real-world care which can help with the of design interventions to help shift patients from the less to more desirable pathways. We conclude that through the process of the care pathway audit cycle, it is possible to learn about real-world activities, better utilize resources, promote safer care, improve quality of care, and help develop more effective interventions.

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.

Aortic Dissection Presenting as Shortness of Breath from Diffuse Alveolar Hemorrhage

BACKGROUND

Aortic dissection is a rare but well-known life-threatening disease that classically presents with tearing chest pain radiating to the back yet can have deceiving clinical presentations.

CASE REPORT

A 54-year-old man with a history of hypertension presented to the emergency department with mild shortness of breath without chest pain. Point-of-care ultrasound (POCUS) detected diffuse B-lines, a dilated aortic root, aortic regurgitation, and pericardial effusion. A computed tomography angiogram confirmed a Stanford type A aortic dissection with diffuse alveolar hemorrhage (DAH), a rare complication of type A aortic dissection involving the posterior aortic wall with extension into the main pulmonary artery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute aortic dissection can present with a wide range of clinical manifestations with a high mortality rate for patients with an untimely diagnosis. Although an intimal flap within the aortic lumen is the characteristic finding on ultrasound, additional POCUS findings of a pericardial effusion, aortic regurgitation, and a dilated aortic root may be seen with proximal dissections. Diffuse B-lines on thoracic POCUS, although commonly associated with pulmonary edema in decompensated heart failure, can be seen in patients with DAH which has a multitude of etiologies, including aortic dissection.

Long-term evaluation of the COVID-19 pandemic impact on acute stroke management: an analysis of the 21-month data from a medical facility in Tokyo

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis and profoundly impacted acute treatment delivery. This study conducted long-term evaluations of the impact of the pandemic on acute stroke management.

Methods

Data from a university-owned medical facility in Tokyo, Japan, were retrospectively analyzed. The number of hospital admissions for stroke and time metrics in the management of patients with acute ischemic stroke were evaluated. A year-over-year comparison was conducted using data from April 2019 to December 2021 to assess the impact of the pandemic.

Results

The year-over-year comparison demonstrated that the number of admissions of patients with stroke and patients who underwent magnetic resonance imaging (MRI), intravenous recombinant tissue plasminogen activator (rt-PA), and thrombectomy during the pandemic remained comparable to the pre-COVID data. However, we found a decrease in the number of admissions of patients with stroke alerts and stroke when hospital cluster infection occurred at this facility and when the region hosted the Tokyo Olympics games during the surge of infection. The door-to-computed tomography time in 2021 was affected. This is plausibly due to the reorganization of in-hospital stroke care pathways after hospital cluster infection. However, no significant difference was observed in the onset-to-door, door-to-MRI, door-to-needle, or door-to-groin puncture times.

Conclusions

We did not observe long-term detrimental effects of the pandemic at this site. Prevention of hospital cluster infections remains critical to provide safe and timely acute stroke management during the pandemic.

Patient Pathways in Cardiology: Should Pharmaceutical and Medical Device Companies Care?

A shared goal of patients, providers, and the companies that produce new therapies is to have these therapies used according to guidelines. Health services specialize in patient care and may lack the capabilities to take a product from conception through to everyday use. This results in a mutually beneficial relationship between health services and industry. The market for cardiovascular drugs is significant, which results in competition between companies. While traditional methods of observational analysis may be able to determine to what extent drugs and devices are being prescribed or implanted by health providers, there is less real-world patient level insight as to why patients are taking (or not taking) these treatments and why one agent is chosen over another. Considering patient pathways is a novel approach that can be utilized to understand real-world patient activities. This approach focuses on the patient flow across the healthcare system and barriers at each stage including identification of patients, diagnostic testing, the decisions on treatment, and prescribing can help identify ways of improving the utilization based on guidelines. It overcomes several assumptions related to patient and clinician decision-making and practical considerations such as geography and availability of health services. In this article, we introduce the concept of patient pathways and why considering them maybe of interest to companies. As significant resources are invested to bring a product to market, this approach can help define if there are missed opportunities for their products to be utilized and potential barriers to implementation.