Working group Stakeholder perspectives on education in aortic dissection

Practice Patterns and Barriers to Vascular Genetic Testing Among Vascular Surgeons

INTRODUCTION

Engaging patients living with or at risk of aortic dissection via the Aortic Dissection Collaborative, physician education in vascular genetics was identified as a research priority. We surveyed vascular surgeons to characterize practice patterns, motivations, and barriers regarding aortopathy genetic testing.

METHODS

An anonymous 27-question survey was distributed on social media platforms between November and December 2022. Domains included demographics, vascular genetic education, testing attitudes and utilization, and experience in treating patients with genetic vascular aortopathies. The analysis included summary statistics and unpaired t-test to compare responses by interest in incorporating testing and practice type.

RESULTS

A total of 171 vascular surgeons from 15 countries responded to the survey (23% trainees). Over half received vascular genetics education during training (59%), and most (86%) were interested in incorporating genetic testing into their practice. Academic surgeons were more likely to have cared for a patient with a known genetic aortopathy over the past year than surgeons in hospital-based and private practices (83% vs. 56% vs. 27%; P < 0.01), to have ever made a referral to a medical geneticist (78% vs. 51% vs. 9%; P < 0.01), and have access to genetic counselors or geneticists (66% vs. 46% vs. 0%; P < 0.01). Barriers to genetic testing were rated as more significant by surgeons in nonacademic practices, with top barriers being insurance coverage of testing, cost of genetic testing, and access to genetic counselors. Evidence-based professional society guidelines were the strongest rated motivating factor for testing incorporation among respondents.

CONCLUSIONS

Vascular surgeon attitudes are not major barriers to incorporating genetic testing for patients with aortopathies; however, practical challenges regarding genetic testing and counseling are barriers to implementation especially for vascular surgeons in nonacademic practices. Future efforts should focus on evidence-based society guidelines, continuing medical education to increase adoption, and facilitating access to genetic counseling.

Dissecting the Medical Student Approach to Chest Pain: A Cross-Sectional Study Focusing on Aortic Dissection

Background and purpose: To understand if medical students consider rarer, but highly fatal conditions, such as acute aortic dissection, when assessing chest pain.

Methods:An online virtual clinical case (in two 'stages') was distributed to medical students. Stage one presented a chest pain scenario, asking participants to give relevant questions, clinical findings, investigations, and differential diagnoses. In the second stage, students were given a detailed case, populated with the aortic dissection ‘red flags’ and asked to re-evaluate their differential diagnosis and investigations. A total of 113 students in their final two years of study, across six United Kingdom (UK) medical schools, were accepted into the study.

Results: During stage one, students were able to assess chest pain with radiation (93%), character (83%), and onset (89%), which were asked commonly. However, students failed to enquire on severity (38%) and important risk factors such as connective tissue disorders (4%) and hypertension (46%), or clinical signs such as blood pressure differences (5%). Myocardial infarction (97%) and pulmonary embolism (78%) were the most considered differentials with acute aortic dissection only considered by 31%. However, in stage two, 73% recognised the acute aortic dissection and 76% were able to request a CT thorax.

Conclusions: Students effectively consider myocardial infarction and pulmonary embolism when assessing chest pain, but often fail to examine acute aortic dissection. This could lead to delayed treatment of a cataclysmic event and may be due to a deficiency in diagnostic synthesis rather than a lack of knowledge. More can be done to ensure these conditions form part of their diagnostic workup.