Type-A aortic dissection: current practice in diagnosis and management

  • Salmasi MY & al.
  • Int J Cardiol
  • 15 Oct 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • The risk for type-A aortic dissection (TAAD) being treated as an acute coronary syndrome (ACS) is significant in patients presenting with ST changes and elevated cardiac enzymes.

Why this matters

  • Implementation of more robust chest pain algorithms may help to increase awareness and use of investigations that can be used to make or exclude TAAD diagnosis.

Study design

  • A “chest pain survey” containing 13 questions was distributed to emergency department (ED) consultants across the UK to assess the range of components of TAAD diagnosis and management. 
  • The survey was divided into 3 categories:
    • initial diagnosis/management,
    • AD-specific investigations and
    • infrastructure to facilitate diagnosis/referral to cardiothoracic services.
  • Funding: None.

Key results

  • Overall, 98% of ED consultants felt that chest pain and ST elevation were sufficient to make a diagnosis of ACS and 58.4% considered the above criteria sufficient to proceed to ACS treatment (including thrombolysis).
  • The initial commitment to the diagnosis of myocardial infarction (OR, 0.31; 95% CI, 0.12-0.83; P=.02) and overlooking signs of unilateral pulse deficit (OR, 0.62; 95% CI, 0.42-0.90; P=.013) were associated with low likelihood to send the patients for CT scan.
  • Overall, 31.7% of ED consultants reported they would never request a CT chest in patients with chest pain and elevated troponin.
  • The absence of an AD algorithm was associated with the use of d-dimer (in the context of troponin positivity) as a useful investigation for differentiating causes of chest pain (OR, 0.31; 95% CI, 0.01-0.64; P=.05).

Limitations

  • The estimated response rate (