Background-In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. Methods and Results-Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1-3, 1.5-24 hours; nϭ894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1-3, 2.4 -24 hours; nϭ751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital (all PϽ0.05 Key Words: aorta Ⅲ aortic Ⅲ aneurysm Ⅲ thoracic Ⅲ diagnosis Ⅲ imaging Ⅲ surgery A cute aortic dissection (AAD) represents a serious cardiovascular emergency, with an associated mortality rate of 1% to 2% per hour immediately after symptom onset in historical untreated patients. 1-3 Timely diagnosis is essential for successful management. Nevertheless, it is known that the relative infrequency of AAD, coupled with clinical presentations that may mimic more common problems, such as acute coronary syndromes, can impede prompt establishment of the AAD diagnosis. Significant delays may exist between hospital arrival and definitive diagnosis and treatment. The precise clinical and diagnostic factors that contribute to these delays are unknown. Editorial see p 1902 Clinical Perspective on p 1918The recent release of an inaugural set of guidelines for the management of thoracic aortic disease by the American College of Cardiology and American Heart Association Task Force on Practice Guidelines will further increase professional awareness of ideal AAD care standards. Data Collection and MeasuresA 290-item data collection instrument 5 was used to collect comprehensive information on patient demographics, medical history, clinical presentation, physical findings, imaging use and results, medical and surgical management, and outcomes. Data were collected at presentation or via physician review of records, and the coordinating center reviewed each submission for face validity, completeness, and clinical appropriateness. Pertinent to this study, data collection included recordings of dates and times of symptom onset, initial presentation (ie, hospital arrival), interhospital transfer (if applicable), diagnosis, surgery, and clinical outcome. The registry collects data on acute dissection only, ie, patients presenting within 14 days of symptom onset. Patients with type A AAD enrolled in IRAD from January 1, 1996, to January 29, 2007, were included in th...

Women ≤ 55 years of age undergoing ACS PCI have significantly greater comorbidities than young men. Despite a higher risk clinical phenotype in women, prasugrel use was significantly lower in women than men. Female sex was associated with a significantly higher risk of 1-year MACE and bleeding than male sex, findings that are attributable to baseline differences. © 2016 Wiley Periodicals, Inc.

"No physician can diagnose a condition he never thinks about."-Michael DeBakey P atients with acute aortic dissection (AAD) have an in-hospital mortality of 26%, and for those patients with type A AAD, the mortality risk is 1% to 2% per hour until emergency surgical repair is performed. 1,2 It is therefore critical that AAD be recognized promptly and that surgical care be provided expeditiously. Data from the International Registry of Acute Aortic Dissection (IRAD) indicate that the median time from emergency department (ED) presentation to definitive diagnosis of AAD is 4.3 hours, with an additional 4 hours between diagnosis and surgical intervention for type A patients. 2,3 A portion of the delay to surgery is often the result of the patient's presenting to smaller community hospitals underequipped to manage emergent AAD. Transfer to high-volume aortic care centers with highly specialized facilities and expertise is routine, but even at such centers, current surgical mortality is 25%. 4 Goals and Vision of the ProgramIn an effort to address factors that delay AAD recognition and optimal management, a standardized, quality-improvement protocol for the regional treatment of AAD was developed and implemented with the goal of providing consistent, integrated, and coordinated care for patients with AAD throughout all phases of care. Modeled, in part, after a successful regional program for ST-segment elevation myocardial infarction, 5 , the specific aims of the program were to decrease the time from hospital arrival to diagnosis and treatment and to improve clinical outcomes for patients with AAD. A collaborative team designed program elements directed at (1) increasing awareness and knowledge of AAD among emergency care providers, (2) standardizing optimal care for AAD through the use of a formal protocol, (3) improving care coordination and communication across disciplines, and (4) providing feedback and quality improvement to treating clinicians. This report highlights key components of the protocol, the process of implementation, and initial clinical outcomes. Methods Local Challenges in ImplementationAn interdisciplinary committee (cardiologists, cardiovascular [CV] surgeons, vascular medicine and surgeons, cardiac anesthesiologists, radiologists, AAD program nurses, community and tertiary hospital ED physicians, and a CV administrator) worked to define an ideal AAD care pathway extending from rural hospital diagnosis to tertiary care hospital discharge, and the following areas were targeted for process improvement: (1) delayed initial diagnosis, (2) nonstandardized diagnostic testing and pharmacotherapy, (3) delays occurring between community hospital presentation and interhospital transfer, (4) delays between AAD center arrival and the initiation of surgical care, (5) delays in availability and preparation of blood products for transfusion, (6) inconsistent provision of intraoperative aortic imaging; and (7) inconsistent follow-up after discharge.

ImportanceEarly data revealed a mortality rate of 1% to 2% per hour for type A acute aortic dissection (TAAAD) during the initial 48 hours. Despite advances in diagnostic testing and treatment, this mortality rate continues to be cited because of a lack of contemporary data characterizing early mortality and the effect of timely surgery.ObjectiveTo examine early mortality rates for patients with TAAAD in the contemporary era.Design, Setting, and ParticipantsThis cohort study examined data for patients with TAAAD in the International Registry of Acute Aortic Dissection between 1996 and 2018. Patients were grouped according to the mode of their intended treatment, surgical or medical.ExposureSurgical treatment.Main Outcomes and MeasuresMortality was assessed in the initial 48 hours after hospital arrival using Kaplan-Meier curves. In-hospital complications were also evaluated.ResultsA total of 5611 patients with TAAAD were identified based on intended treatment: 5131 (91.4%) in the surgical group (3442 [67.1%] male; mean [SD] age, 60.4 [14.1] years) and 480 (8.6%) in the medical group (480 [52.5%] male; mean [SD] age, 70.9 [14.7] years). Reasons for medical management included advanced age (n = 141), comorbidities (n = 281), and patient preference (n = 81). Over the first 48 hours, the mortality for all patients in the study was 5.8%. Among patients who were medically managed, mortality was 0.5% per hour (23.7% at 48 hours). For those whose intended treatment was surgical, 48-hour mortality was 4.4%. In the surgical group, 51 patients (1%) died before the operation.Conclusions and RelevanceIn this study, the overall mortality rate for TAAAD was 5.8% at 48 hours. For patients in the medical group, TAAAD had a mortality rate of 0.5% per hour (23.7% at 48 hours). However, among those in the surgical group, 48-hour mortality decreased to 4.4%.