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The risk of misdiagnosis in acute thoracic aortic dissection: a review of current guidelines
  1. M Yousuf Salmasi1,
  2. Nina Al-Saadi1,
  3. Philip Hartley1,
  4. Omar A Jarral1,
  5. Shahzad Raja2,
  6. Muthana Hussein3,
  7. Julian Redhead4,
  8. Ulrich Rosendahl2,
  9. Christoph A Nienaber5,
  10. John R Pepper2,
  11. Aung Y Oo6,
  12. Thanos Athanasiou1
  1. 1 Department of Surgery and Cancer, Imperial College London, London, UK
  2. 2 Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
  3. 3 Emergency Medicine, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
  4. 4 Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
  5. 5 Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  6. 6 Cardiac Surgery, Barts Health NHS Trust, London, UK
  1. Correspondence to Dr M Yousuf Salmasi, Surgery and Cancer, Imperial College London, London SW7 2BU, UK; y.salmasi{at}imperial.ac.uk

Abstract

Acute aortic syndrome and in particular aortic dissection (AAD) persists as a cause of significant morbidity and mortality despite improvements in surgical management. This clinical review aims to explore the risks of misdiagnosis, outcomes associated with misdiagnosis and evaluate current diagnostic methods for reducing its incidence.

Due to the nature of the pathology, misdiagnosing the condition and delaying management can dramatically worsen patient outcomes. Several diagnostic challenges exist, including low prevalence, rapidly propagating pathology, non-discrete symptomatology, non-specific signs, analogy with other acute conditions and lack of management infrastructure. A similarity to acute coronary syndromes is a specific concern and risks patient maltreatment. AAD with malperfusion syndromes are both a cause of misdiagnosis and marker of disease complication, requiring specifically tailored management plans from the emergency setting.

Despite improvements in diagnostic measures, including imaging modalities and biomarkers, misdiagnosis of AAD remains commonplace and current guidelines are relatively limited in preventing its occurrence. This paper recommends the early use of AAD risk scoring, focused echocardiography and most importantly, fast-tracking patients to cross-sectional imaging where the suspicion of AAD is high. This has the potential to improve the diagnostic process for AAD and limit the risk of misdiagnosis. However, our understanding remains limited by the lack of large patient datasets and an adequately audited processes of emergency department practice.

  • aortic dissection or intramural hematoma
  • cardiac imaging and diagnostics
  • cardiac computer tomographic (CT) imaging
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Footnotes

  • Contributors MYS and TA are responsible for the overall content of the manuscript. Specific contributions: MYS: conception, manuscript preparation, writing, data collection, analysis, review. NAS, PH: writing, data collection, review. OAJ: writing, review. SR: review. MH, JRP, UR: review. CAN, JRP, AO, TA: conception, review.

  • Funding This study was supported by the NIHR Imperial College Biomedical Research Centre (P69559).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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