How to prevent inadvertent emergency anticoagulation in acute type A aortic dissection: when in doubt, don’t

Zschaler, Silke; Schmidt, Gerard; Kukucka, Marian; Syrmas, Georg; Zaschke, Lisa; Kurz, Sabine

doi:10.21037/cdt.2018.10.13

Cited by 6 publications

(3 citation statements)

References 25 publications

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“…Troponin elevation in AD is not infrequent and mostly related to a non-atherothrombotic coronary process, such as dissection extension into either the coronary ostium leading to coronary hypoperfusion or occlusion and/or myocardial oxygen demand/supply mismatch related to hemodynamic alterations from AD complications. In patients with AAS misdiagnosed as ACS, the employment of anticoagulation and antiplatelet agents can theoretically have lethal consequences [ 11 ] by worsening and fueling the dissection process. Therefore, making the distinction early in the natural history of the disease is of uttermost importance, as in the case of our patient.…”

Section: Discussionmentioning

confidence: 99%

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

Escabí-Mendoza¹,

Diaz-Rodriguez²,

Gonzalez-Bravo³

et al. 2023

Cureus

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Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle’s syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.

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Section: Discussionmentioning

confidence: 99%

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

Escabí-Mendoza¹,

Diaz-Rodriguez²,

Gonzalez-Bravo³

et al. 2023

Cureus

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“…They found that patients were more likely to be anticoagulated if they presented with chest pain and the absence of back pain with ECG changes 22 . AD is the worst diagnostic scenario for a patient attending with chest pain and should always be prioritized as a differential to be ruled out 23 …”

Section: A Cause For Concern: Delay In Diagnosis Of Type a Admentioning

confidence: 99%

From ER to OR—Type A aortic dissection delay dilemma

et al. 2021

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Background and Aim of Study Aortic dissection (AD) remains a life‐threatening and time‐critical condition. The classical presentation involves sudden onset, sharp “tearing” chest pain radiating to the back. However, it can present with a myriad of symptoms, leading to a high occurrence of misdiagnosis and delay in treatment. Methods and Results A review of the available literature published on AD and diagnostic delays. A systematic review of the literature performed via PubMed and Google scholar using key search terms such as “type A,” “aortic dissection,” “delay,” “misdiagnosis,” and synonyms. The Boolean operator used to narrow results specifically to diagnostic elements of AD. A current lack of data collection has impeded the systematic analysis and review of this condition making it difficult to assess reasons for delay. A review of the literature showed a large variation in the presentation of those that have acute AD. Often the presentation mimics other more common conditions such as acute coronary syndrome. Lack of awareness amongst clinicians means that it is often not considered as a differential. Furthermore, the lack of a discriminator for patients being triaged leads to diagnostic delay; this is exacerbated by limited accessibility to diagnostic tests such as CT. Conclusion Based on the current literature, collaborative data collection, regular audit, national guidance, and communication between Royal Colleges will improve awareness, reduce diagnostic delays, and shine greater light on the issue.

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“…Der erste präklinische Kontakt ist in > 70 % der Fälle der Rettungsdienst [3,4]. Hier spielen frühzeitige differenzialdiagnostische Überlegungen eine entscheidende Rolle für weitere Diagnostik und Management [5]. Wird vom Notarzt der Verdacht auf ein akutes Aortensyndrom geäußert, erfolgt die Diagnostik im Primärkrankenhaus erheblich schneller [6,7] [10].…”

Section: Medizinischer Hintergrundunclassified

Medikolegale Aspekte des präklinischen Managements von „akuten Aortensyndromen“

et al. 2020

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ZusammenfassungAkute Aortensyndrome sind in der Versorgung äußerst zeitkritische Ereignisse, die letztendlich nur in einer hoch spezialisierten medizinischen Einrichtung definitiv versorgt werden können. Um Leben und Gesundheit der Notfallpatienten zu erhalten, steht der schnellstmögliche Transport unter Inanspruchnahme von Sonderrechten mit dem nächsten geeigneten Rettungsmittel im Vordergrund. Die Disposition eines erst später verfügbaren Intensivtransportwagens ist aus medizinrechtlicher Sicht als höchst bedenklich anzusehen.

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How to prevent inadvertent emergency anticoagulation in acute type A aortic dissection: when in doubt, don’t

Cited by 6 publications

References 25 publications

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

From ER to OR—Type A aortic dissection delay dilemma

Medikolegale Aspekte des präklinischen Managements von „akuten Aortensyndromen“

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