What do these three people have in common?
Lucille Ball (comedienne)
Jonathan Larson (wrote the musical "Rent")
John Ritter (comedian)
I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren't actually very common. Here are some scary examples:
- A pulse deficit in the carotid, brachial, and femoral arteries is only present 15% of the time.
- A tearing or ripping quality of pain is present in only 50% of patients.
- Not all patients have a widened mediastinum or abnormal aortic contour (only 78.7%).
Reference
Hagan P et al. The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease JAMA. 2000; 283(7), 897-903. DOI: 10.1001/jama.283.7.897
Free PDF article for download
Michelle:
ReplyDeleteSome of the figures in the chart may be a little misleading because of spectrum bias -- they apply to cases of aortic dissection that have already been diagnosed. The actual statistics can be quite different when a patient presents early with mild and/or nonspecific symptoms.
For example, it may be true that 79% of patients with dissection when they are diagnosed have abnormal CXR findings -- that may be one of the reasons the diagnosis was made. This is often a point put forward by plaintiff's attorneys in medical-legal cases: "If only the doctor had ordered a simple chest x-ray when the patient presented with mild epigastric/chest pain!" However, there is good evidence that on initial presentation well under half the CXRs will be abnormal.
Two important quotations:
1) "In fact, difficulty in diagnosis, delayed diagnosis or failure to diagnose [aortic dissection] are so common as to approach the norm for this disease, even in the best hands, rather than the exception." (Elefteriades et al. Litigation in Nontraumatic Aortic Diseases -- A Tempest in the Malpractice Maelstrom. Cardiology 2008;109:263-272.
2) "There is no disease more conducive to clinical humility than aneurysm of the aorta." Sir William Osler
Hi Leon:
ReplyDeleteThanks for eloquently describing the pitfalls in risk-stratifying for diseases using retrospective data. I don't think there will ever be a prospective study though on dissection where every chest/back pain patient receives a CT angiogram of the chest, especially in the setting of CT irradiation risks. We can only do our best and have a low-threshold to obtain a D-Dimer (which has ok sensitivity for aortic dissection) and Chest CT angio. Experience has taught me to definitely be humble with aortic diseases. Thanks for commenting!
Whenever I read IRAD, I realize the limitations that we ED docs have when diagnosing AD. Some patients can present with "absoulutely no pain at all."
ReplyDeleteThanks for another PV.
I know what you mean, JD. I sometimes wish I read IRAD more and other times I wish I never read it at all. Scary data.
ReplyDeleteWow I don't think I would think of aortic dissection if they came in with NO pain. Last dissection I diagnosed in the ED had severe excruciating pain unrelieved after multiple doses of dilaudid. He did have pain down into his thighs too. That is scary.
ReplyDeleteI know, scary right? I wonder if the major of these pain-less presentations are those who are either obtunded, intubated, or present with syncope and are still altered.
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