Diagnosis Of Acute Aortic Syndrome Research Articles

ThP8.10 - Diagnostic accuracy of aortic dissection detection risk score and D-dimer to rule out aortic emergencies in the emergency department – outcomes from a multicentre study

Abstract Background Acute aortic syndromes (AAS) are rare but potentially fatal vascular emergencies affecting the aorta, including aortic dissection, penetrating aortic ulcers, intramural haematoma and occasionally aortic aneurysm rupture. The variety of presentations can make it difficult to decide which patients should have definitive computerised tomography aortogram (CTA) imaging. This study aims to evaluate the diagnostic accuracy of the aortic dissection detection risk score (ADD-RS) combined with D-dimer to rule out AAS in the emergency department. Methods This retrospective cohort study involved two centres. Results of patients who had CTAs between 1st March 2020 – 31st March 2022 were reviewed. Patient data including demographics and laboratory results were logged from day of presentation. Results A total of 435 CTAs were requested. Patients with diagnosis of AAS had higher mean total ADD-RS (1.6 vs 1.0, P<0.05) and higher mean D-dimer (8,836 vs 1,462ng/mL, P<0.05). The use of ADD-RS≤1/normal D-dimer had sensitivity of 100.0% and specificity of 27.9%. Negative predictive value (NPV) was 100%. In this cohort, there were no false negatives. Conclusion This study appears to support the implementation of a new guideline in these departments that incorporates ADD-RS and D-dimer to aid deciding next steps for suspected AAS. In this cohort ADD-RS ≤1 and negative D-dimer (<500ng/mL) had high sensitivity, and low failure rate and could have prevented at least 70 and up to 229 patients from receiving unnecessary radiation. The results suggest that in low-risk patients, with ADD-RS≤1/negative D-dimer, AAS can be safely ruled out. New guidelines could prevent patients receiving unnecessary radiation, contrast induced nephropathy and reduce burden of stretched emergency departments.

Evaluating current acute aortic syndrome pathways: Collaborative Acute Aortic Syndrome Project (CAASP)

Abstract Background Diagnosis of acute aortic syndrome is challenging and associated with high perihospital mortality rates. The study aim was to evaluate current pathways and understand the chronology of acute aortic syndrome patient care. Method Consecutive patients with acute aortic syndrome imaging diagnosis between 1 January 2018 and 1 June 2021 were identified using a predetermined search strategy and followed up for 6 months through retrospective case note review. The UK National Interventional Radiology Trainee Research and Vascular and Endovascular Research Network co-ordinated the study. Results From 15 UK sites, 620 patients were enrolled. The median age was 67 (range 25–98) years, 62.0% were male and 92.9% Caucasian. Type-A dissection (41.8%) was most common, followed by type-B (34.5%); 41.2% had complicated acute aortic syndrome. Mode of presentation included emergency ambulance (80.2%), self-presentation (16.2%), and primary care referral (3.6%). Time (median (i.q.r.)) to hospital presentation was 3.1 (1.8–8.6) h and decreased by sudden onset chest pain but increased with migratory pain or hypertension. Time from hospital presentation to imaging diagnosis was 3.2 (1.3–6.5) h and increased by family history of aortic disease and decreased by concurrent ischaemic limb. Time from diagnosis to treatment was 2 (1.0–4.3) h with interhospital transfer causing delay. Management included conservative (60.2%), open surgery (32.2%), endovascular (4.8%), hybrid (1.4%) and palliative (1.4%). Factors associated with a higher mortality rate at 30 days and 6 months were acute aortic syndrome type, complicated disease, no critical care admission and age more than 70 years (P < 0.05). Conclusions This study presents a longitudinal data set linking time-based delays to diagnosis and treatment with clinical outcomes. It can be used to prioritize research strategies to streamline patient care.

Diagnostic accuracy of alternative biomarkers for acute aortic syndrome: a systematic review

BackgroundD-dimer is the only biomarker currently recommended in guidelines for the diagnosis of acute aortic syndrome (AAS). We undertook a systematic review to determine whether any alternative biomarkers could be...

Correlation analysis of gamma-glutamyl transferase to lymphocyte ratio and patients with acute aortic syndrome in China: a propensity score-matched analysis.

Acute aortic syndrome (AAS) is a life-threatening condition in which there is a fracture in the integrity of the aortic wall. gamma-glutamyl transferase to lymphocyte ratio (GLR) is recognized as a risk factor for liver cirrhosis, fibrosis, and hepatocellular carcinoma. However, there are no clinical reports of GLR and AAS. We attempted to determine whether GLR level is associated with AAS in patients from the Chaoshan region of southern China. A total of 2,384 patients were recruited in this study and were divided into AAS and no-AAS groups according to the results of CT angiography of the thoracoabdominal aorta. Univariate and multivariate logistic regression was performed to identify risk factors for the occurrence of AAS. ROC was applied to assess the value of D-Dimer, GLR alone, or in combination for the diagnosis of AAS. And a 1:1 propensity score-matched analysis was performed. Multivariate logistics regression analysis indicated that male, age, hypertension, diabetes, creatinine, D-dimer, and GLR were independent risk factors of AAS patients in the before propensity score-matching cohort. After propensity score-matching, it showed that D-dimer, GLR [OR 3.558(1.891, 6.697); p < 0.001] were independent risk factors of AAS patients. Before propensity score-matching, the area under the curve (AUC) was 0.822 of GLR and 0.767 of D-dimer. When both clinical backgrounds were adjusted, the AUC was 0.773 of GLR and 0.631 of D-dimer. GLR showed high specificity (80.5% and 77.1%), and D-dimer showed high sensitivity (84.7% and 73.6%) in the before and after propensity score-matching cohort. GLR and D-dimer were independent risk factors of acute aortic syndrome. D-dimer in combination with GLR is more valuable than a single indicator for diagnosing acute aortic syndrome.

Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study

BackgroundIn patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting. ObjectivesWe assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of-care ultrasound (POCUS) and d-dimer (single/age-adjusted cutoff), to select patients for AAI. MethodsThis prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and d-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes. ResultsWithin 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0 % (95 % CI, 0–0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46–50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4–9 %, vs standard cutoff). ConclusionsThe integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted d-dimer maximized efficiency.CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT04430400

Impact of misdiagnosis on the treatment and prognosis of acute aortic syndrome

Abstract Funding Acknowledgements None. Introduction Acute aortic syndrome (AAS) embraces a spectrum of pathologies with relatively low prevalence but associated with high mortality. The clinical presentation of AAS is highly variable and the differential diagnosis with other much more common diseases such as myocardial infarction (AMI) or pulmonary embolism (PE) is often difficult to achieve. AAS detection requires a high index of suspicion and the delay in diagnosis is associated with increased morbidity and mortality. Purpose The aim of this study is to characterize the diagnostic approach to AAS patients in the emergency department (ED) and to study the impact of the initial diagnostic suspicion on the treatment and prognosis of patients with AAS. Methods The "Aorta Code" is an inter-hospital and interdisciplinary care protocol for the management of patients with AAS in a 4-Hospital network. Patients with AAS were prospectively and consecutively collected from 2019 to 2022. The sample was classified into two groups according to whether the initial suspicion was AAA or another clinical entity. The diagnosis of AAS was established by computed tomography in all patients. Time, clinical, treatment and prognostic variables were analyzed. Results A total of 113 patients with AAS were included. Of them, only 38% (34) were initially suspected of having an AAS (Figure). AMI and PE were the initial diagnosis in 34% of patients (Figure). There were no significant differences in age, history of hypertension or other cardiovascular risk factors between the groups (table). Anterior chest pain was more frequent in the "AAS-suspicion" group. The diagnostic time delay was longer in patients with initial misdiagnosis (table). Patients with type A AAS with initial misdiagnosis underwent surgery in a lower proportion (table). Although the differences were not significant, patients with initial misdiagnosis had more postoperative complications and higher mortality. Conclusion It is essential to maintain a high index of diagnostic suspicion for AAS in the ED. Initial misdiagnosis is associated with a delayed diagnosis, delayed surgical treatment and a lower rate of surgery. In addition, although it is a small sample size, this group of patients had more postoperative complications and higher mortality.

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review.

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Unveiling the Intricacies of Acute Aortic Syndromes through Imaging: A Case Series

Acute Aortic Syndrome (AAS) comprises of three distinct pathological conditions: Aortic Dissection (AD), Penetrating Atherosclerotic Ulcer (PAU), and Intramural Haematoma (IMH). Although AAS and its emergencies are not common occurrences, they are considered highly dangerous and potentially fatal. Clinically, differentiating between the various types of aortic syndromes can be challenging. The prognosis of these conditions significantly depends on speedy and precise analysis. Therefore, present study emphasised the critical role of radiology in the diagnosis of AASs, with Contrast-Enhanced Computed Tomography (CECT) being the quickest and most consistent imaging modality. In this case series, four cases of AASs are presented, comprising three cases of AD and a case of PAU in a patient with infrarenal aortic occlusion. Notably, one of the dissection cases was accompanied by renal ischaemia. Recognising acute aortic emergencies promptly is essential for saving lives.

An audit of the use of unenhanced imaging in the diagnosis of acute aortic syndrome

An audit of the use of unenhanced imaging in the diagnosis of acute aortic syndrome

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

BackgroundThe 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...

Evaluation of the Canadian Clinical Practice Guidelines Risk Prediction Tool for Acute Aortic Syndrome: The RIPP Score.

Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality rate. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making (RIPP score). The aim of this study is to validate the diagnostic accuracy of this tool and assess its performance in comparison to other risk prediction tools that have been developed. This was a historical case-control study. Consecutive cases and controls were recruited from three academic emergency departments from 2002-2020. Cases were identified through an admission, discharge, or death certificated diagnosis of acute aortic syndrome. Controls were identified through presenting complaint of chest, abdominal, flank, back pain, and/or perfusion deficit. We compared the clinical decision tools' C statistic and used the DeLong method to test for the significance of these differences and report sensitivity and specificity with 95% confidence intervals. We collected data on 379 cases of acute aortic syndrome and 1340 potential eligible controls; 379 patients were randomly selected from the final population. The RIPP score had a sensitivity of 99.7% (98.54-99.99). This higher sensitivity resulted in a lower specificity (53%) compared to the other clinical decision aids (63-86%). The DeLong comparison of the C statistics found that the RIPP score had a higher C statistic than the ADDRS (-0.0423 (95% confidence interval -0.07-0.02); P < 0.0009) and the AORTAs score (-0.05 (-0.07 to -0.02); P = 0.0002), no difference compared to the Lovy decision tool (0.02 (95% CI -0.01-0.05 P < 0.25)) and decreased compared to the Von Kodolitsch decision tool (0.04 (95% CI 0.01-0.07 P < 0.008)). The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. It has the potential to improve diagnosis of AAS in the emergency department.

The D-Dimer to Troponin Ratio Is a Novel Marker for the Differential Diagnosis of Thoracic Acute Aortic Syndrome from Non-ST Elevation Myocardial Infarction.

Thoracic acute aortic syndrome (AAS) and non-ST elevation myocardial infarction (NSTEMI) have similar clinical presentations, making them difficult to differentiate. This study aimed to identify useful biomarkers for the differential diagnosis of thoracic AAS and NSTEMI. This was a retrospective observational study. consecutive adult patients who visited the emergency department for acute chest pain between January 2015 and December 2021 diagnosed with thoracic AAS or NSTEMI. Clinical variables, including D-dimer (μg/mL) and high-sensitivity troponin T (ng/mL, hs-TnT) levels, were compared between the groups. A total of 52 (30.1%) and 121 (69.9%) patients were enrolled in the thoracic AAS and NSTEMI groups, respectively. Logistic regression analysis revealed that the D-dimer to hs-TnT (D/T) ratio (odds ratio (OR), 1.038; 95% confidence interval (CI), 1.020-1.056; p < 0.001) and the thrombolysis in myocardial infarction (TIMI) score (OR, 0.184; 95% CI, 0.054-0.621; p = 0.006) were associated with thoracic AAS. The D/T ratio had an area under the receiver operating characteristic curve (AUC) of 0.973 (95% CI, 0.930-0.998), and the optimal cutoff value was 81.3 with 91.4% sensitivity and 96.2% specificity. The TIMI score had an AUC of 0.769 (95% CI, 0.644-0.812), and the optimal cutoff value was 1.5 with 96.7% sensitivity and 38.5% specificity. the D/T ratio may be a simple and useful parameter for differentiating thoracic AAS from NSTEMI.

Comparisons of potential values of D-dimer and the neutrophil- to-lymphocyte ratio in patients with suspected acute aortic syndrome

ObjectivesThis study aimed to investigate and compare the discriminative performance and clinical utility of D-dimer and the neutrophil-to-lymphocyte ratio (NLR) in the early differential diagnosis of acute aortic syndrome (AAS). MethodsThe consecutive patients presenting to Tianjin Chest Hospital for suspected AAS were retrospectively investigated between June 2018 and December 2021. The baseline values of D-dimer and NLR were analyzed and compared in the study population. The discriminative ability of D-dimer and NLR was illustrated and compared using the area under the receiver operating characteristic (ROC) curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Clinical utility was evaluated by means of decision curve analysis (DCA). ResultsIn the study period, a total of 697 participants suspected of having AAS were enrolled and 323 had a final diagnosis of AAS. The baseline level of NLR as well as D-dimer was higher in patients with AAS. The use of NLR showed excellent overall diagnostic performance for AAS with a comparable AUC to that of D-dimer (0.845 vs. 0.822, P > 0.05). The reclassification analyses further confirmed that NLR had better discriminative properties for AAS with a significant NRI of 66.1% and IDI of 12.4% (P < 0.001). Moreover, NLR provided higher net benefit than D-dimer as shown by DCA. Similar results were observed in subgroup analyses according to the different classes of AAS. ConclusionsNLR outperformed D-dimer with improved discriminative performance and superior clinical utility in identifying AAS. As a more readily available biomarker, NLR may be a reliable alternative to D-dimer for the screening of suspected AAS in clinical practice.

Diagnosis of Acute Aortic Syndromes on Non-Contrast CT Images with Radiomics-Based Machine Learning

We aimed to detect acute aortic syndromes (AAS) on non-contrast computed tomography (NCCT) images using a radiomics-based machine learning model. A total of 325 patients who underwent aortic CT angiography (CTA) were enrolled retrospectively from 2 medical centers in China to form the internal cohort (230 patients, 60 patients with AAS) and the external testing cohort (95 patients with AAS). The internal cohort was divided into the training cohort (n = 135), validation cohort (n = 49), and internal testing cohort (n = 46). The aortic mask was manually delineated on NCCT by a radiologist. Least Absolute Shrinkage and Selection Operator regression (LASSO) was used to filter out nine feature parameters; the Support Vector Machine (SVM) model showed the best performance. In the training and validation cohorts, the SVM model had an area under the curve (AUC) of 0.993 (95% CI, 0.965-1); accuracy (ACC), 0.946 (95% CI, 0.877-1); sensitivity, 0.9 (95% CI, 0.696-1); and specificity, 0.964 (95% CI, 0.903-1). In the internal testing cohort, the SVM model had an AUC of 0.997 (95% CI, 0.992-1); ACC, 0.957 (95% CI, 0.945-0.988); sensitivity, 0.889 (95% CI, 0.888-0.889); and specificity, 0.973 (95% CI, 0.959-1). In the external testing cohort, the ACC was 0.991 (95% CI, 0.937-1). This model can detect AAS on NCCT, reducing misdiagnosis and improving examinations and prognosis.

CT characteristics and clinical implications of acute type A aortic intramural hematoma.

Computed tomography (CT) has been increasingly used in the diagnosis of acute aortic syndrome, and a number of high-risk CT imaging features have been reported. We aimed to identify CT imaging findings suggesting high-risk for acute aortic syndrome by examining clinical outcomes of patients with acute type A aortic intramural hematoma (TAIMH). This retrospective study analyzed the relationship of clinical patient characteristics and imaging features with mortality and aortic events in 63 patients receiving initial medical treatment for TAIMH. Multivariate regression analysis was used to determine the predictors of aortic events, and the Kaplan-Meier method was used to analyze survival and aortic events. During a median follow-up of 4.2 years, 25 patients experienced aortic events and 40% of these occurred within 7 days of admission. In total, 12 patients experienced aortic death and 12 patients underwent open aortic surgery or endovascular stenting for aortic disease. In multivariate regression analysis, penetrating atherosclerotic ulcers (PAUs) or ulcer-like projections (ULPs) (P = 0.04) and pericardial effusion (P = 0.03) were independent predictors of aortic events. In the Cox regression model, PAUs/ULPs (P = 0.04) and pericardial effusion (P = 0.04) were independently associated with lower aortic event-free survival. Identification of high-risk CT features is important for clinical decision-making during TAIMH treatment. Early and frequent CT imaging follow-up is required in patients receiving medical treatment. PAUs/ULP and pericardial effusion were the strongest predictors of adverse aortic events.

A sinister needle in an enormous haystack: A clinician survey regarding Acute Aortic Syndrome diagnostic practice in United Kingdom Emergency Departments

Acute Aortic Syndrome (AAS) is a life-threatening condition associated with high diagnostic uncertainty. This results in an unacceptable number of missed cases, which contributes to its high mortality. We designed and distributed a survey to Emergency Departments (EDs) across the United Kingdom to establish the standard practice for investigation and diagnosis of AAS across the UK. 56 EDs across the UK responded. The majority of these did not have a formal work-up pathway for AAS. The estimated CT scanning rates and missed cases of AAS were highly variable between departments. This suggests variation in practice and diagnostic uncertainty. Given its time sensitive nature, the need for a more standardised diagnostic pathway for AAS in EDs is evident. This may aid clinicians rule out AAS more safely and reduce the number of missed cases, which would in turn reduce the high morbidity and mortality associated with AAS.

Progress of CT aortic angiography combined with coronary artery in the evaluation of acute aortic syndrome.

Acute aortic syndrome (AAS) is a group of cardiovascular diseases that seriously threaten human life and health. AAS patients are often complicated with coronary artery disease and other related diseases, which require rapid and clear clinical diagnosis to avoid serious adverse events. In recent years, with the progress of science and technology, a variety of computer tomography (CT) angiography techniques have been applied in the clinic, and the diagnosis rate of AAS with coronary heart disease (CAD) has greatly increased. At the same time, the development of surgical technology and endovascular repair technology has significantly reduced the mortality and complication rate of AAS surgery. In the clinical diagnosis of AAS and related diseases, CT aortic angiography (CTA) combined with coronary CTA is increasingly applied to identify related diseases. Here, the current research progress on the technique of aortic CTA combined with coronary CTA is reviewed.

Novel views on finding an old foe: non-contrast computed tomography in the diagnosis of acute aortic syndromes.

Novel views on finding an old foe: non-contrast computed tomography in the diagnosis of acute aortic syndromes.

Patient-Friendly Summary of the ACR Appropriateness Criteria: Suspected Acute Aortic Syndrome.

Acute aortic syndrome (AAS) is caused by abnormalities affecting the wall of the aorta. The aorta is the main blood vessel that carries blood from the heart to the rest of the body. People with AAS typically have sudden severe pain in the front or back of their chest. Risk factors include high blood pressure and family history. Rapid diagnosis of AAS is important to guide medical or surgical treatment and to avoid serious harm, including death.

Emergency CT misdiagnosis in acute aortic syndrome.

This cross-sectional study assessed the accuracy of emergency CT reports at presentation in acute aortic syndrome (AAS). Retrospective identification of cases of AAS presenting within a large health board with three acute hospitals receiving adult patients between January 2013 and December 2016. CT studies and reports at presentation were reviewed for discrepancies related to diagnosis, complications and classification by two cardiovascular radiologists. The specialist interest of the original reporters, clinically suspected diagnosis at referral for CT and technical adequacy of the scans were also assessed. False-positive diagnoses were identified and evaluated separately. Among 88 consecutive confirmed cases of AAS at least one discrepancy was identified in 31% (n = 27), including failure to identify or misinterpretation of the AAS itself in 15% (n = 13), haemorrhage in 13% (n = 11), branch involvement in 9% (n = 8), and misclassification in 3% (n = 3). All discrepancies occurred among the 80% (n = 70) of cases reported by radiologists without specialist cardiovascular interest. 26% (n = 23/88) of AAS cases were not clinically suspected at referral for CT and although this was associated with suboptimal protocols, only 51% of CT scans among suspected cases were technically adequate. Seven false-positive diagnoses were identified, three of which related to motion artefact. Significant discrepancies are common in the emergency CT assessment of positive cases AAS and this study highlights important pitfalls in CT technique and interpretation. The absence of discrepancies among radiologists with specialist cardiovascular interest suggests both suspected and confirmed cases warrant urgent specialist review. CT angiography is central to the diagnosis of AAS; however, significant radiology discrepancies are common among non-specialists. This study highlights important pitfalls in both CT technique as well as interpretation and supports routine specialist cardiovascular imaging input in the emergency assessment of AAS.