Diagnosis and management of acute Type-A aortic dissection in emergency departments: Results of a UK national survey. (1st February 2020)

• Record Type: Journal Article
• Authors: Salmasi, M. Yousuf; Hartley, Philip; Hussein, Muthana; Jarral, Omar; Pepper, John; Nienaber, Christoph; Athanasiou, Thanos
• Is Part Of: International journal of cardiology. Volume 300(2020)
• Page Start: 50
• Page End: 59
• Publication Date: 2020-02-01
• Subjects: Aortic dissection -- Chest pain -- Diagnosis -- Emergency department -- Survey; Cardiology -- Periodicals; Electronic journals; 616.12
• DOI: 10.1016/j.ijcard.2019.09.074
• Languages: English
• ISSNs: 0167-5273

Abstract

Abstract: Background: Type A-aortic dissection (TAAD) is a life-threatening diagnosis made in the emergency department (ED). Many presentations mimic acute coronary syndrome (ACS) and over a third of TAAD patients present with raised cardiac enzymes, many of whom have ACS-like changes on the electrocardiogram. The aim of this study was to assess the current practice in diagnosis and management of TAAD. Methods: Between April and October 2018, a structured survey was distributed to ED Consultants across the UK. Questions surrounded: i) simulated clinical scenarios which mimicked ACS in the early stages (where TAAD could simultaneously be the diagnosis); and ii) ED infrastructure for TAAD management. Results: Responses were received from 175 ED consultants across 70 hospital Trusts. In the context of chest pain and ST elevation, 97% of ED consultants considered this sufficient to diagnose ACS, and over half (54%) agreed with committing to treatment (including the use of thrombolysis) prior to further investigation. Early committers to ACS treatment were statistically less likely to ever order a CT scan or d-dimer (OR 0.31, 95% CI 0.12–0.83, p = 0.02). In total, 32% of consultants reported they would ever request a CT chest in the context of chest pain and elevated troponin. The lack of an AD algorithm was the strongest predictor of clinicians avoiding the use of more definitive investigations for TAAD (OR 0.31, 95% CI 0.01–0.64, p = 0.05). Conclusions: In TAAD patients presenting with chest pain and elevated cardiac enzymes there is a high probability of ACS treatment being commenced and a significant risk of failing to request the necessary imaging to diagnose TAAD. Highlights: 74% of UK hospital emergency departments participated in this national survey. The index of suspicion for aortic dissection in chest pain remains a challenge. In aortic dissection mimicking ACS, patients are at risk to receive ACS treatment. Early committers to ACS treatment are likely to never order a CT scan or d-dimer.