Risk Factors for Diagnostic Delay in Acute Aortic Dissection

Rapezzi, Claudio; Longhi, Simone; Graziosi, Maddalena; Biagini, Elena; Terzi, Francesca; Cooke, Robin M. T.; Quarta, Candida Cristina; Sangiorgi, Diego; Ciliberti, Paolo; Pasquale, Giuseppe Di; Branzi, Angelo

doi:10.1016/j.amjcard.2008.07.013

Cited by 65 publications

(60 citation statements)

References 21 publications

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“…Electrocardiogram in AOD may reveal myocardial ischemia or infarction in 17% of all dissections-more often in type A (24%) and less frequently in type B (10%)-and abnormal electrocardiogram may be a predictor of death (2,3). Similarly, 10-20% of patients with type A AOD may have abnormal troponin values (4,5), and troponin is the single most reliable biomarker of myocardial necrosis.…”

Section: Introductionmentioning

confidence: 96%

Ischemia‐modified albumin in acute aortic dissection

Sbarouni

Γεωργιάδου

Marathias

et al. 2010

Clinical Laboratory Analysis

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Section: Introductionmentioning

confidence: 96%

Ischemia‐modified albumin in acute aortic dissection

Sbarouni

Γεωργιάδου

Marathias

et al. 2010

Clinical Laboratory Analysis

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“…In AAD, cTn may be increased in up to 18% of patients at presentation and is reportedly associated with a 3-to 4-fold increased risk of delayed inhospital diagnosis (17 ). In a study of 66 patients with the eventual diagnosis of AAD, increased cTn occurred in 7 patients (11%) and coronary compromise as a consequence of aortic dissection occurred in 4 patients (6%) (15 ).…”

Section: Cardiac and Vascularmentioning

confidence: 99%

Increases of Cardiac Troponin in Conditions other than Acute Coronary Syndrome and Heart Failure

2009

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Background: Although cardiac troponin (cTn) is a cornerstone marker in the assessment and management of patients with acute coronary syndrome (ACS) and heart failure (HF), cTn is not diagnostically specific for any single myocardial disease process. This narrative review discusses increases in cTn that result from acute and chronic diseases, iatrogenic causes, and myocardial injury other than ACS and HF.Content: Increased cTn concentrations have been reported in cardiac, vascular, and respiratory disease and in association with infectious processes. In cases involving acute aortic dissection, cerebrovascular accident, treatment in an intensive care unit, and upper gastrointestinal bleeding, increased cTn predicts a longer time to diagnosis and treatment, increased length of hospital stay, and increased mortality. cTn increases are diagnostically and prognostically useful in patients with cardiac inflammatory diseases and in patients with respiratory disease; in respiratory disease cTn can help identify patients who would benefit from aggressive management. In chronic renal failure patients the diagnostic sensitivity of cTn for ACS is decreased, but cTn is prognostic for the development of cardiovascular disease. cTn also provides useful information when increases are attributable to various iatrogenic causes and blunt chest trauma.Summary: Information on the diagnostic and prognostic uses of cTn in conditions other than ACS and heart failure is accumulating. Although increased cTn in settings other than ACS or heart failure is frequently considered a clinical confounder, the astute physician must be able to interpret cTn as a dynamic marker of myocardial damage, using clinical acumen to determine the source and significance of any reported cTn increase.

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“…3,22 Determination of the most significant sources of delay in terms of patient characteristics and diagnostic approaches will better equip physicians, and particularly the unacquainted physician, to promptly and accurately recognize these often-lethal events.…”

Section: Educationmentioning

confidence: 99%

Multidisciplinary Standardized Care for Acute Aortic Dissection

Harris

Strauss

Duval

et al. 2010

Circ: Cardiovascular Quality and Outcomes

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"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.

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Risk Factors for Diagnostic Delay in Acute Aortic Dissection

Cited by 65 publications

References 21 publications

Ischemia‐modified albumin in acute aortic dissection

Ischemia‐modified albumin in acute aortic dissection

Increases of Cardiac Troponin in Conditions other than Acute Coronary Syndrome and Heart Failure

Multidisciplinary Standardized Care for Acute Aortic Dissection

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