Delayed diagnosis of aortic dissection

Being female or having atypical pain is associated with delays to diagnosis of aortic dissection. This recent study also shows that arrival in a non-tertiary hospital is another factor associated with delayed diagnosis. Patients may present with fever, abdominal pain, or heart failure (due to acute aortic insufficiency) that lead the clinician down alternative diagnostic algorithms. The strongest factors associated with operative delay were prolonged time from presentation to diagnosis, race other than white, and history of coronary artery bypass surgery.
Worth remembering at this point that in 2010 the AHA published Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

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; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1-3, 2.4-24 hours; n=751). 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 P<0.05). The largest relative DTRs were for fever (DTR=5.11; P<0.001) and transfer from nontertiary hospital (DTR=3.34; P<0.001). Delay in time from diagnosis to surgery was associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital (all P<0.001). The strongest factors associated with operative delay were prolonged time from presentation to diagnosis (DTR=1.35; P<0.001), race other than white (DTR=2.25; P<0.001), and history of coronary artery bypass surgery (DTR=2.81; P<0.001).
Conclusions- Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.

Correlates of Delayed Recognition and Treatment of Acute Type A Aortic Dissection: The International Registry of Acute Aortic Dissection (IRAD)
Circulation. 2011 Nov 1;124(18):1911-1918

One thought on “Delayed diagnosis of aortic dissection”

  1. Sadly, this study’s conclusions about the known delay between presentation and diagnosis appear to be par for the course when it comes to women’s heart disease. In fact, another paper on cardiac misdiagnoses reported in the New England Journal of Medicine found that women under 55 are SEVEN TIMES more likely to be misdiagnosed in mid-cardiac event and sent home from Emergency Departments.
    There may be some good news coming, however, after two female SCAD patients successfully spurred Mayo Clinic cardiologists to undertake two new studies on their shared diagnosis. More info on this at: “All The SCAD Ladies! Put Your Hands Up!” –

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