https://doi.org/10.4081/ecj.2023.11153
Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis
Submitted: 13 January 2023
Accepted: 6 March 2023
Published: 28 March 2023
Accepted: 6 March 2023
Abstract Views: 1179
PDF: 509
Supplementary Materials: 82
Supplementary Materials: 82
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
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Objectives: To understand why the diagnosis of AAS is missed in the ED, and to characterise the presenting features of cases in which a diagnosis of AAS was missed.
Methods: A retrospective case series cohort study was performed, identifying and analysing cases where AAS was misdiagnosed in three UK EDs between 1st January 2011 and 31st December 2020.
Results: 43 cases were included, 22 of which were type A aortic dissections. The most common incorrect presumed diagnoses made were acute coronary syndrome (28%), pulmonary embolism (12%) and ‘non-specific chest pain’ (12%). In 31 cases (72%) there was no evidence from the notes that the clinician had considered AAS in the differential diagnosis. In 10 cases (23%), AAS was considered, but the clinician was falsely reassured by atypical or resolved symptoms, clinical examination, or normal chest x-ray.
Conclusions: ED clinicians may miss AAS by not considering it as a possibility, being falsely reassured by atypical or resolved symptoms, or mistaking it for other more common conditions. Further prospective work is necessary to establish the role of diagnostic aids and biomarkers in UK EDs.
Erbel R, Aboyans V, Boileua C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J 2014;35:2873-926.
DOI: https://doi.org/10.1093/eurheartj/ehu281
Rotella JA, Yeoh M. Taming the zebra: Unravelling the barriers to diagnosing aortic dissection. Emerg Med Australas 2018;30:119-121.
DOI: https://doi.org/10.1111/1742-6723.12871
NHS Resolution. Clinical negligence claims in Emergency Departments in England; High value and fatality-related claims. NHS Resolution 2022. Accessed Feb 2023. Available from: https://resolution.nhs.uk/wp-content/uploads/2022/03/1-NHS-Resolution-ED-report-High-value-and-fatalities.pdf
Healthcare Safety Investigation Branch.org.uk. Delayed recognition of acute aortic dissection. Accessed 28 Feb 2023. Available from: https://www.hsib.org.uk/investigations-and-reports/delayed-recognition-of-acute-aortic-dissection/delayed-recognition-of-acute-aortic-dissection/
Harris KM, Strauss CE, Eagle KA, et al. Correlates of delayed recognition and treatment of acute type A aortic dissection the International Registry of Acute Aortic Dissection (IRAD). Circulation 2011;124:1911-8.
DOI: https://doi.org/10.1161/CIRCULATIONAHA.110.006320
Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol 2015;66:350-8.
DOI: https://doi.org/10.1016/j.jacc.2015.05.029
Lovy AJ, Bellin E, Levsky JM, et al. Preliminary development of a clinical decision rule for acute aortic syndromes. Am J Emerg Med 2013;31:1546–50.
DOI: https://doi.org/10.1016/j.ajem.2013.06.005
Ohle R, Anjum O, Bleeker H, et al. Variation in emergency department use of computed tomography for investigation of acute aortic dissection. Emerg Radiol 2018;25:293–8.
DOI: https://doi.org/10.1007/s10140-018-1587-x
Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR /STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation 2010;121:266–369.
DOI: https://doi.org/10.1161/CIR.0b013e3181d4739e
Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation 2011;123:2213–8.
DOI: https://doi.org/10.1161/CIRCULATIONAHA.110.988568
Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection detection risk score alone or with d-dimer: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2020;9:S32-9.
DOI: https://doi.org/10.1177/2048872620901831
Hill JM, Murphy TG, Fermann GJ. Aortic dissection detection risk score: a clinical decision rule that needs some parenting. Acad Emerg Med 2019;26:695–7.
DOI: https://doi.org/10.1111/acem.13636
Ohle R, Yan JW, Yadav K, et al. Diagnosing acute aortic syndrome: a Canadian clinical practice guideline. CMAJ 2020;192:832-43.
DOI: https://doi.org/10.1503/cmaj.200021
Morello F, Bima P, Pivetta E, et al. Development & validation of a simplified probability assessment score integrated with age-adjusted d-dimer for diagnosis of acute aortic syndromes. J Am Heart Assoc 2021;10:e018425.
DOI: https://doi.org/10.1161/JAHA.120.018425
Think Aorta.net. Accessed Feb 2023. Available from: https://www.thinkaorta.net/
The Royal College of Emergency Medicine & The Royal College of Radiologists. Best Practice Guideline: Diagnosis of Thoracic Aortic Dissection in the Emergency Department. 2021. Accessed Feb 2023. Available from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr216_diagnosis_of_thoracic_aortic_dissection.pdf
Kurabayashi M, Miwa N, Ueshima D, et al. Factors leading to failure to diagnose acute aortic dissection in the emergency room. J Cardiol 2011;58:287-93.
DOI: https://doi.org/10.1016/j.jjcc.2011.07.008
Bressler M, Klein E, Shayowitz M, et al. A case of late diagnosis of acute aortic dissection involving the carotid arteries in a patient presenting with signs of acute ischemic stroke. Am J Case Rep 2020;21:e919271.
DOI: https://doi.org/10.12659/AJCR.919271
Usui T, Suzuki K, Niinami H, Sakai S. Aortic dissection diagnosed on stroke computed tomography protocol: a case report. J Med Case Rep 2021;15:299.
DOI: https://doi.org/10.1186/s13256-021-02850-1
Huang YC, Sung SF, Liu KT. Painless acute aortic dissection may present as a stroke; risky markers that could be identified on hospital arrival. J Acute Med 2017;7:93-100.
Al-Wahaibi K, Al-Dhuhli H, Diputado T, Alzadjali N. Acute cardiovascular emergency: missed killer in the emergency room. Oman Med J 2008;23:112-5.
Nazerian P, Mueller C, Soeiro AM, et al. ADvISED Investigators. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018;137:250-8.
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.029457
Nagra K, Coulden R, McMurtry MS. A type A aortic dissection missed by non-cardiac gated contrast-enhanced computed tomography due to an aortic root dissection flap masquerading as an aortic valve apparatus: a case report. J Med Case Rep 2013;7:285.
DOI: https://doi.org/10.1186/1752-1947-7-285
Vardhanabhut V, Nicol E, Morgan-Hughes G, et al. Recommendations for accurate CT diagnosis of suspected acute aortic syndrome (AAS) –on behalf of the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT). Br J Radiol 2016,89;20150705
DOI: https://doi.org/10.1259/bjr.20150705
Croskerry, P. ED cognition: Any decision by anyone at any time. Can J Emerg Med 2014;16:13-9.
DOI: https://doi.org/10.2310/8000.2013.131053
McLatchie R, Gupta A, Wilson S, et al . A sinister needle in an enormous haystack: A clinician survey regarding Acute Aortic Syndrome diagnostic practice in United Kingdom Emergency Departments. Emerg Care J 2022;18:10758.
DOI: https://doi.org/10.4081/ecj.2022.10758
Asha SE, Miers JW. A systematic review and meta-analysis of d-dimer as a rule-out test for suspected acute aortic dissection. Ann Emerg Med 2015;66:368–78.
DOI: https://doi.org/10.1016/j.annemergmed.2015.02.013
How to Cite
McLatchie, R., Wilson, S., Reed, M., Ticehurst, F., Easterford, K., Alawiye, S., Cowan, A., & Gupta, A. (2023). Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis. Emergency Care Journal, 19(1). https://doi.org/10.4081/ecj.2023.11153
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