Acil Serviste Akut Aort Diseksiyonlarının Değerlendirilmesi: Geriye Dönük Çalışma

Öz

Aortic dissection (AD) is a life-threatening emergency that has a mortality rate of around 27% even when optimal conditions are met. Atypical process of the disease which can mimic other critical conditions makes it harder to diagnose. The study aimed to determine Emergency department presentations and factors that influence the diagnostic process, emergency department, and in-hospital mortalities of acute AD patients. This study is a single-centered retrospective observational study. Patients with ICD-10 codes for AD in their digital files were analyzed. Patients were categorized into Stanford Type A or B dissections according to their computerized tomography scans. Also, the patients were compared in terms of survival. Eighty-eight patients had an acute AD and the mean age was 61,90±12,67 years. According to Stanford Classification, 68 patients had Type A dissection. Altered mental status and syncope were detected more in Type A (p=0.003 and p=0.001). Bilateral arm blood pressure readings differential was more in Type A (p=0.007). Blood products were used and endotracheal intubation was performed more in Type A (p=0.002 and p=0.005). Patients who had bilateral arm blood pressure differential had 3.5-fold, who had developed cardiac arrest in ED had 5.07-fold, who got blood product transfusions had 5.41-fold more risk of death. [OR:3.50; (CI 95% 1.36-8.94) p=0.009, OR: 5.07; (CI 95% 1.18-21.39) p=0.027 and OR: 5.41; (CI 95% 1.97-14.78) p=0.001 respectively]. The mortality rates in ED and in-hospital were 12.5% and 61.4% respectively. Aortic dissections will stay as important clinical conditions which management in ED is crucial. Atypical presentation of AD and the nature of the disease cause delays in diagnoses. AD should be considered in the foreground in patients presenting with syncope and altered mental status. When there is a clinical suspicion the scan of the aorta with computerized tomography must be ordered rapidly.

Anahtar Kelimeler

• Aort diseksiyonu
• Acil servis
• Stanford sınıflaması

Evaluation of Acute Aortic Dissections in the Emergency Department: A Retrospective Study

Öz

Aortic dissection (AD) is a life-threatening emergency that has a mortality rate of around 27% even when optimal conditions are met. Atypical process of the disease which can mimic other critical conditions makes it harder to diagnose. The study aimed to determine Emergency department presentations and factors that influence the diagnostic process, emergency department, and in-hospital mortalities of acute AD patients. This study is a single-centered retrospective observational study. Patients with ICD-10 codes for AD in their digital files were analyzed. Patients were categorized into Stanford Type A or B dissections according to their computerized tomography scans. Also, the patients were compared in terms of survival. Eighty-eight patients had an acute AD and the mean age was 61,90±12,67 years. According to Stanford Classification, 68 patients had Type A dissection. Altered mental status and syncope were detected more in Type A (p=0.003 and p=0.001). Bilateral arm blood pressure readings differential was more in Type A (p=0.007). Blood products were used and endotracheal intubation was performed more in Type A (p=0.002 and p=0.005). Patients who had bilateral arm blood pressure differential had 3.5-fold, who had developed cardiac arrest in ED had 5.07-fold, who got blood product transfusions had 5.41-fold more risk of death. [OR:3.50; (CI 95% 1.36-8.94) p=0.009, OR: 5.07; (CI 95% 1.18-21.39) p=0.027 and OR: 5.41; (CI 95% 1.97-14.78) p=0.001 respectively]. The mortality rates in ED and in-hospital were 12.5% and 61.4% respectively. Aortic dissections will stay as important clinical conditions which management in ED is crucial. Atypical presentation of AD and the nature of the disease cause delays in diagnoses. AD should be considered in the foreground in patients presenting with syncope and altered mental status. When there is a clinical suspicion the scan of the aorta with computerized tomography must be ordered rapidly.

Anahtar Kelimeler

• Aortic dissection
• Emergency department
• Stanford classification

Kaynakça

1. 1. Ankel F. Aortic dissection. In: Marx JA, Hockberger RS, Walls RM, et al, editor. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby Elsevier Publishing; 2010. p. 1088–92.
2. 2. Clouse WD, Hallett JW, Schaff HV, Spittell PC, Rowland CM, Ilstrup DM, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc. 2004 Feb;79(2):176–80.
3. 3. Cantrill SV, Brown MD, Burton JH, Diercks DB, Gemme SR, Gerardo CJ, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection. Annals of Emergency Medicine. 2015 Jan 1;65(1):32-42.e12.
4. 4. Ohle R, Kareemi HK, Wells G, Perry JJ. Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta-analysis. Acad Emerg Med. 2018 Apr;25(4):397–412.
5. 5. Nazerian P, Ascione G, Castelli M, Capretti E, Ranaldi F, Bonaccorsi L, et al. Additional risk factors for evaluation of suspected acute aortic syndromes in the emergency department. Acad Emerg Med. 2021 Feb 22;
6. 6. Nazerian P, Mueller C, Soeiro A de M, Leidel BA, Salvadeo SAT, Giachino F, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018 Jan 16;137(3):250–8.
7. 7. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000 Feb 16;283(7):897–903.
8. 8. Lombardi JV, Hughes GC, Appoo JJ, Bavaria JE, Beck AW, Cambria RP, et al. Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections. Ann Thorac Surg. 2020 Mar;109(3):959–81.

9. 9. JCS Joint Working Group. Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection (JCS 2011): digest version. Circ J. 2013;77(3):789–828.
10. 10. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014 Nov 1;35(41):2873–926.
11. 11. Sobczyk D, Nycz K. Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic dissection. Cardiovasc Ultrasound [Internet]. 2015 Mar 25 [cited 2021 Apr 26];13. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396118/
12. 12. Wang Y, Yu H, Cao Y, Wan Z. Early Screening for Aortic Dissection With Point-of-Care Ultrasound by Emergency Physicians: A Prospective Pilot Study. J Ultrasound Med. 2020 Jul;39(7):1309–15.
13. 13. Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation. 2021 Apr 1;161:115–51.
14. 14. Ersel M, Aksay E, Kiyan S, Bayraktaroglu S, Yuruktumen A, Ozsarac M, et al. Can D-dimer testing help emergency department physicians to detect acute aortic dissections? Anadolu Kardiyol Derg. 2010 Oct 1;10(5):434–9.
15. 15. Mehta RH, O’Gara PT, Bossone E, Nienaber CA, Myrmel T, Cooper JV, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol. 2002 Aug 21;40(4):685–92.
16. 16. Meredith EL, Masani ND. Echocardiography in the emergency assessment of acute aortic syndromes. European Journal of Echocardiography. 2009 Jan 1;10(1):i31–9.
17. 17. Olsson C, Thelin S, Ståhle E, Ekbom A, Granath F. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation. 2006 Dec 12;114(24):2611–8.
18. 18. Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013 Feb;145(2):385-390.e1.
19. 19. Gawinecka J, Schönrath F, von Eckardstein A. Acute aortic dissection: pathogenesis, risk factors and diagnosis. Swiss Medical Weekly [Internet]. 2017 Aug 25 [cited 2021 Jun 18];147(3334). Available from: https://smw.ch/article/doi/smw.2017.14489
20. 20. Akutsu K. Etiology of aortic dissection. Gen Thorac Cardiovasc Surg. 2019 Mar;67(3):271–6.
21. 21. Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM. Population-based study of incidence and outcome of acute aortic dissection and pre-morbid risk-factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013 May 21;127(20):2031–7.
22. 22. Sievers H-H, Rylski B, Czerny M, Baier ALM, Kreibich M, Siepe M, et al. Aortic dissection reconsidered: type, entry site, malperfusion classification adding clarity and enabling outcome prediction. Interact Cardiovasc Thorac Surg. 2020 Mar 1;30(3):451–7.
23. 23. Kozinski M, Krintus M, Kubica J, Sypniewska G. High-sensitivity cardiac troponin assays: From improved analytical performance to enhanced risk stratification. Crit Rev Clin Lab Sci. 2017 May;54(3):143–72.
24. 24. Shah KS, Maisel AS, Fonarow GC. Troponin in Heart Failure. Heart Fail Clin. 2018 Jan;14(1):57–64.
25. 25. Vagnarelli F, Corsini A, Bugani G, Lorenzini M, Longhi S, Bacchi Reggiani ML, et al. Troponin T elevation in acute aortic syndromes: Frequency and impact on diagnostic delay and misdiagnosis. Eur Heart J Acute Cardiovasc Care. 2016 Nov;5(7):61–71.
26. 26. Bonnefoy E, Godon P, Kirkorian G, Chabaud S, Touboul P. Significance of serum troponin I elevation in patients with acute aortic dissection of the ascending aorta. Acta Cardiol. 2005 Apr;60(2):165–70.
27. 27. Gao Z, Qin Z, An Z, Hou C, Wang L, Jin J. Prognostic Value of Preoperative Hemoglobin Levels for Long-Term Outcomes of Acute Type B Aortic Dissection Post-thoracic Endovascular Aortic Repair. Front Cardiovasc Med [Internet]. 2020 Nov 5 [cited 2021 Jun 18];7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693721/
28. 28. Cevik AA, Dolgun H, Oner S, Tokar B, Acar N, Ozakin E, et al. Elevated lactate level and shock index in nontraumatic hypotensive patients presenting to the emergency department. Eur J Emerg Med. 2015 Feb;22(1):23–8.
29. 29. Bennett JM, Wise ES, Hocking KM, Brophy CM, Eagle SS. Hyperlactemia Predicts Surgical Mortality in Patients Presenting With Acute Stanford Type-A Aortic Dissection. J Cardiothorac Vasc Anesth. 2017 Feb;31(1):54–60.
30. 30. Sultan I, Bianco V, Aranda-Michel E, Kilic A, Serna-Gallegos D, Navid F, et al. The use of blood and blood products in aortic surgery is associated with adverse outcomes. J Thorac Cardiovasc Surg. 2021 Mar 15; S0022-5223(21)00452-9. doi: 10.1016/j.jtcvs.2021.02.096. Epub ahead of print. PMID: 33838909.