Prevalence of acute aortic syndromes and aortic aneurysms retrieved incidentally in the emergency department — What should be the threshold of suspicion for the clinician?

Abstract

Penetrating aortic ulcer (PAU), intramural aortic haematoma (IMH) and aortic dissection represent a continuum of pathological entities collectively known as acute aortic syndromes (AAS). Despite their lethal potential and the life-saving role of a prompt intervention, the prevalence of these syndromes is frequently underestimated in the emergency setting. With the present observational study, we attempted to document the actual prevalence of acute aortic syndromes in the busy Emergency Department of a tertiary hospital, as well as the prevalence of previously undiagnosed increases in the diameter of the thoracic and abdominal aneurysms of aorta. We examined the chest and abdominal CT scans (PACSystem) of all female and male adults (ages 18–99 years) that presented to the Emergency Department of our institution over a period of forty days. The assessment of each CT scan was followed by a cross-check of our results with those reported by the attending Radiologist. The results, along with the demographics of each patient, were further statistically analyzed. A total of 991 individual cases were examined, 511 females and 480 males, 473 18–49yo vs. 519 ≥50yo. The respective prevalence was as follows: PAU: 9 cases; female:male = 5:4; young:old = 0:9. IMH: 8 cases; female:male = 6:2; young:old = 0:8. Aortic Dissections: 7 cases; female:male = 2:5; young:old = 0:7. Among a total of 72 cases with aortic pathology, 58 had abdominal and/or thoracic aneurysmatic aortic dilatation, isolated or co-existent with an acute aortic syndromes. Univariable and multivariable analysis was performed to elucidate the correlation of each entity with various factors. The prevalence of acute aortic syndromes among patients presenting to the Emergency Department is very low to justify the performance of a screening test, but is not negligible, especially regarding the elderly. The most significant correlated factor was age >65 years, both for aneurysmatic aortic dilatations (OR 25.25, 95%CI 6.06–105-1, p<0.001) and acute aortic syndromes (OR 21.45, 95%CI 5.09–90.28, p<0.001), whereas gender was not significantly correlated, nor was indication for the performance of CT scan, with the exception of trauma in the multivariable analysis for acute aortic syndromes (OR 3.71, 95%CI 1.15–11.95, p<0.03). In brief, the emergency physician or surgeon on call should keep a high level of suspicion for detecting previously undiagnosed aortic pathology in elderly patients presenting to the emergency department with pain as chief complaint.