Early recognition of acute thoracic aortic dissection and aneurysm

World Journal of Emergency Surgery

Byron Patton¹  Barbara A Zeifer³  Thomas Bernik¹  David Lucido¹  Charles M Geller¹  Kar-Mun Woo²  Michal Poplawski¹  Eyal Menashe¹  Aaron J Wengrofsky¹  Kei Suzuki¹  I Michael Leitman¹ 

[1] Departments of Surgery, Albert Einstein College of Medicine-Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA;Emergency Medicine, Albert Einstein College of Medicine-Beth Israel Medical Center, New York, NY, USA;Radiology, Albert Einstein College of Medicine-Beth Israel Medical Center, New York, NY, USA

关键词: Aortic dissection;    Aortic aneurysm;    Thoracic aorta;    Acute coronary syndrome;   

Others  :  791597
DOI  :  10.1186/1749-7922-8-47

 received in 2013-08-27, accepted in 2013-10-31,  发布年份 2013

【 摘 要 】

Background

Thoracic aortic dissection (TAD) and aneurysm (TAA) are rare but catastrophic. Prompt recognition of TAD/TAA and differentiation from acute coronary syndrome (ACS) is difficult yet crucial. Earlier identification of TAA/TAD based upon routine emergency department screening is necessary.

Methods

A retrospective analysis of patients that presented with acute thoracic complaints to the ED from January 2007 through June 2012 was performed. Cases of TAA/TAD were compared to an equal number of controls which consisted of patients with the diagnosis of ACS. Demographics, physical findings, EKG, and the results of laboratory and radiological imaging were compared. P-value of > 0.05 was considered statistically significant.

Results

In total, 136 patients were identified with TAA/TAD, 0.36% of patients that presented with chest complaints. Compared to ACS patients, TAA/TAD group was older (68.9 vs. 63.2 years), less likely to be diabetic (13% vs 32%), less likely to complain of chest pain (47% vs 85%) and head and neck pain (4% vs 17%). The pain for the TAA/TAD group was less likely characterized as tight/heavy in nature (5% vs 37%). TAA/TAD patients were also less likely to experience shortness of breath (42% vs. 51%), palpitations (2% vs 9%) and dizziness (2% vs 13%) and had a greater incidence of focal lower extremity neurological deficits (6% vs 1%), bradycardia (15% vs. 5%) and tachypnea (53% vs. 22%). On multivariate analysis, increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction were independent predictors of ACS.

Conclusions

Increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction can be used to differentiate acute coronary syndromes from thoracic aortic dissections/aneurysms.

【 授权许可】

   
2013 Leitman et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Woo KM, Schneider JI: High-risk chief complaints I: chest pain-the big three. Emerg Med Clin North Am 2009, 27(4):685-712.
• [2]Assar AN, Zarins CK: Ruptured abdominal aortic aneurysm: a surgical emergency with many clinical presentations. Postgrad Med J 2009, 85:268-273.
• [3]Mehta RH, Suzuki T, Hagan PG, et al.: Predicting death in patients with acute type a aortic dissection. Circulation 2002, 105(2):200-206.
• [4]Klompas M: Does this patient have an acute thoracic aortic dissection? JAMA 2002, 287(17):2262-2272.
• [5]Booher AM, Isselbacher EM, Nienaber CA, et al.: The IRAD classification system for characterizing survival after aortic dissection. Am J Med 2013, 126(8):730.
• [6]Ramanath VS, Oh JK, Sundt TM, et al.: Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc 2009, 84(5):465-481.
• [7]Legras A, Bruzzi M, Nakashima K, et al.: Risk factors for hospital death after surgery for type A aortic dissection. Asian Cardiovasc Thorac Ann 2012, 20(3):269-274.
• [8]Tanaka M, Kimura N, Yamaguchi A, et al.: In-hospital and long-term results of surgery for acute type A aortic dissection: 243 Consecutive Patients. Ann Thorac Cardiovasc Surg 2012, 18:18-23.
• [9]Shiga T, Wajima Z, Apfel CC, et al.: Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med 2006, 166(13):1350-1356.
• [10]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: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010, 121(13):266-369.
• [11]Isselbacher EM: Thoracic and abdominal aortic aneurysms. Circulation 2005, 111:816-828.
• [12]O’Gara PT: Aortic aneurysm. Circulation 2003, 107:43-45.
• [13]Kuang S-Q, Guo D-C, Prakash SK: Recurrent chromosome 16p13.1 duplications are a risk factor for aortic dissections. PLoS Genet 2011, 7:e1002118.
• [14]Das D, Gawdzik J, Dellefave-Castillo L, et al.: S100a12 expression in thoracic aortic aneurysm is associated with increased risk of dissection and perioperative complications. J Am Coll Cardiol 2012, 60:775-785.
• [15]Chua M, Ibrahim I, Neo X, et al.: Acute aortic dissection in the ed: risk factors and predictors for missed diagnosis. Am J Emerg Med 2012, 30:1622-1626.
• [16]Prakash S, Pedroza C, Khalil Y, et al.: Diabetes and reduced risk for thoracic aortic aneurysms and dissections: a nationwide case–control study. J Am Heart Assoc 2012, 1:jah3-e000323.
• [17]Miyama N, Dua MM, Yeung JJ, et al.: Hyperglycemia limits experimental aortic aneurysm progression. J Vasc Surg 2010, 52:975-983.
• [18]Keller PF, Carballo D, Roffi M: Diabetes and acute coronary syndrome. Minerva Med 2010, 101(2):81-104.
• [19]Weber T, Högler S, Auer J, et al.: D-dimer in acute aortic dissection. CHEST Journal 2003, 123:1375-1378.
• [20]Eggebrecht H, Naber CK, Bruch C, et al.: Value of plasma fibrin d-dimers for detection of acute aortic dissection. J Am Coll Cardiol 2004, 44:804-809.
• [21]Sutherland A, Escano J, Coon TP: D-dimer as the sole screening test for acute aortic dissection: a review of the literature. Ann Emerg Med 2008, 52(4):339-343.
• [22]Suzuki T, Katoh H, Watanabe M, et al.: Novel biochemical diagnostic method for aortic dissection: results of a prospective study using an immunoassay of smooth muscle myosin heavy chain. Circulation 1996, 93:1244-1249.
• [23]Marill KA: Serum d-dimer is a sensitive test for the detection of acute aortic dissection: a pooled meta-analysis. J Emerg Med 2008, 34(4):367-376.
• [24]Koracevic GP: Pragmatic classification of the causes of high D-dimer. Am J Emerg Med 2009, 27(8):1016.e5-7.
• [25]Aboulafia DM, Aboulafia ED: Aortic aneurysm-induced disseminated intravascular coagulation. Ann Vasc Surg 1996, 10(4):396-405.
• [26]Lentini S, Perrotta S: Aortic dissection with concomitant acute myocardial infarction: from diagnosis to management. J Emerg Trauma Shock 2011, 4(2):273-278.
• [27]Ankel F: Aortic dissection. In Rosen’s emergency medicine: Concepts and clinical practice. Edited by Marx JH, Walls RM. Philadelphia: PA, Mosby Elsevier Publishing; 2010:1088-1092.
• [28]Luo JL, Wu CK, Lin YH, et al.: Type A aortic dissection manifesting as acute myocardial infarction: still a lesson to learn. Acta Cardiol 2009, 64(4):499-504.
• [29]Lai V, Tsang WK, Chan WC, et al.: Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection. Emerg Radiol 2012, 19(4):309-15.
• [30]Nathan DP, Boonn W, Lai E, et al.: Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J Vasc Surg 2012, 55(1):10-5.
• [31]Shah BN, Ahmadvazir S, Pabla JS, et al.: The role of urgent transthoracic echocardiography in the evaluation of patients presenting with acute chest pain. Eur Jour Emerg Med 2012, 19(5):277-83.
• [32]Cecconi M, Chirillo F, Costantini C, et al.: The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome. Am Heart J 2012, 163:112-8.