Abstract
Study Objective
Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis
with a nonspecific presentation. Ascending aortic dissection is associated with aortic
dilation, which can be determined by emergency physician focused cardiac ultrasound
(EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time
to diagnosis for AAD.
Methods
We performed a retrospective review of patients treated at 1 of 3 affiliated emergency
departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies
were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary
outcomes were time to disposition, misdiagnosis rate, and mortality.
Results
Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified
32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median
time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157)
minutes vs 226 (IQR, 109-1449) minutes in the non–EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the
non–EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non–EP
FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP
FOCUS vs 205 (IQR, 114-342) minutes for non–EP FOCUS (P = .27).
Conclusions
Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared
with patients who do not receive EP FOCUS. We recommend assessment of the thoracic
aorta be performed routinely during cardiac ultrasound in the emergency department.
Abbreviations:
AAD (ascending aortic dissection), CTA (computed tomography angiography), EP FOCUS (emergency physician focused cardiac ultrasound)To read this article in full you will need to make a payment
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References
- Acute aortic dissection: clinician update.Circulation. 2010; 122: 184-188https://doi.org/10.1161/CIRCULATIONAHA.110.958975
- Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2011; 124: 1911-1918https://doi.org/10.1161/CIRCULATIONAHA.110.006320
- 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease.J Am Coll Cardiol. 2010; 55: e27-e129https://doi.org/10.1016/j.jacc.2010.02.015
- Litigation in nontraumatic aortic diseases—a tempest in the malpractice maelstrom.Cardiology. 2008; 109: 263-272https://doi.org/10.1159/000107790
- Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection.Ann Emerg Med. 2015; 65: 32-42.e2https://doi.org/10.1016/j.annemergmed.2014.11.002
- Echocardiography in the emergency assessment of acute aortic syndromes.Eur J Echocardiogr. 2009; 10: i31-i39https://doi.org/10.1093/ejechocard/jen251
- Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.J Am Soc Echocardiogr. 2010; 23: 1225-1230https://doi.org/10.1016/j.echo.2010.10.005
- Limited role of aortic size in the genesis of acute type A aortic dissection.Eur J Cardiothorac Surg. 2005; 28: 857-863https://doi.org/10.1016/j.ejcts.2005.10.013
- Aortic diameter > =5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2007; 116: 1120-1127https://doi.org/10.1161/CIRCULATIONAHA.107.702720
- What is new in dilatation of the ascending aorta? Review of current literature and practical advice for the cardiologist.Circulation. 2011; 123: 924-928https://doi.org/10.1161/CIRCULATIONAHA.110.949131
- Point-of-care focused cardiac ultrasound for the assessment of thoracic aortic dimensions, dilation, and aneurysmal disease.Acad Emerg Med. 2012; 19: 244-247https://doi.org/10.1111/j.1553-2712.2011.01279.x
- Diagnostic performance of focused cardiac ultrasound performed by emergency physicians for the assessment of ascending aorta dilation and aneurysm.Acad Emerg Med. 2015; 22: 536-541https://doi.org/10.1111/acem.12650
- Diagnostic performance of emergency transthoracic focus cardiac ultrasound in suspected acute type A aortic dissection.Intern Emerg Med. 2014; 9: 665-670https://doi.org/10.1007/s11739-014-1080-9
- Chart reviews in emergency medicine research: where are the methods?.Ann Emerg Med. 1996; 27: 305-308
- Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies.Ann Emerg Med. 2014; 64: 292-298https://doi.org/10.1016/j.annemergmed.2014.03.025
- The “5Es” of emergency physician-performed focused cardiac ultrasound: a protocol for rapid identification of effusion, ejection, equality, exit, and entrance.Acad Emerg Med. 2015; 22: 583-593https://doi.org/10.1111/acem.12652
- The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.JAMA. 2000; 283: 897https://doi.org/10.1001/jama.283.7.897
- Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection.Eur Heart J. 2010; 31: 472-479https://doi.org/10.1093/eurheartj/ehp505
- Aortic dissection: review of value and limitations of two-dimensional echocardiography in a six-year experience.J Am Soc Echocardiogr. 1989; 2: 17-24
- Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection.Clin Cardiol. 1999; 22: 345-352
- Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves.J Am Coll Cardiol. 1992; 19: 283-288
- Frequency of aortic root dilation in children with a bicuspid aortic valve.Am J Cardiol. 2004; 94: 1337-1340https://doi.org/10.1016/j.amjcard.2004.07.130
- Current issues with emergency cardiac ultrasound probe and image conventions.Acad Emerg Med. 2008; 15: 278-284https://doi.org/10.1111/j.1553-2712.2008.00052.x
Article Info
Publication History
Published online: December 12, 2015
Accepted:
December 8,
2015
Received in revised form:
November 17,
2015
Received:
October 14,
2015
Footnotes
☆There were no sources of support for this project, and there are no conflicts of interest to disclose. No individual was paid to provide manuscript advice, writing, or editing. Only those authors listed had control over the data, how it was analyzed, interpreted, and presented within the manuscript.
☆☆Presented: Oral Presentation Connecticut College of Emergency Physicians Annual Meeting. Hartford, CT September 30th, 2015.
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
