Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room
Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD. We conducted a retrospective analysis of 127 consecutive patie...
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| Veröffentlicht in: | PloS one 2015-11, Vol.10 (11), p.e0141929-e0141929 |
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| creator | Hirata, Kazuhito Wake, Minoru Takahashi, Takanori Nakazato, Jun Yagi, Nobuhito Miyagi, Tadayoshi Shimotakahara, Junichi Mototake, Hidemitsu Tengan, Toshiho Takara, Tsuyoshi R Yamaguchi, Yutaka |
| description | Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.
We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.
An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).
WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital. |
| doi_str_mv | 10.1371/journal.pone.0141929 |
| format | Article |
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We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.
An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).
WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0141929</identifier><identifier>PMID: 26559676</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Abdomen ; Acute coronary syndromes ; Acute Disease ; Aged ; Aged, 80 and over ; Aorta ; Aortic Aneurysm - diagnosis ; Aortic Aneurysm - physiopathology ; Aortic dissection ; Aortic Dissection - diagnosis ; Aortic Dissection - physiopathology ; Cardiology ; Computed tomography ; Confidence intervals ; Coronary vessels ; Development and progression ; Diabetes Mellitus - diagnosis ; Diabetes Mellitus - physiopathology ; Diagnosis ; Diagnosis, Differential ; Diagnostic Errors ; Differential diagnosis ; Echocardiography ; Electrocardiography ; Emergency medical care ; Emergency medical services ; Emergency Service, Hospital - statistics & numerical data ; Emergency vehicles ; Female ; Heart attacks ; Heart Failure - diagnosis ; Heart Failure - physiopathology ; Heart surgery ; Hospital emergency services ; Hospitals ; Humans ; Hypertension - diagnosis ; Hypertension - physiopathology ; Life assessment ; Male ; Medical diagnosis ; Medical imaging ; Medical research ; Middle Aged ; Mortality ; Multivariate Analysis ; Pain - diagnosis ; Pain - physiopathology ; Patients ; Physicians ; Precision medicine ; Prognosis ; Quartiles ; Retrospective Studies ; Time Factors ; Veins & arteries</subject><ispartof>PloS one, 2015-11, Vol.10 (11), p.e0141929-e0141929</ispartof><rights>COPYRIGHT 2015 Public Library of Science</rights><rights>2015 Hirata et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2015 Hirata et al 2015 Hirata et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c758t-506e658d86cf163b4e1c36f938dfc01259997d80603ee9a05dee99fd4b33aed93</citedby><cites>FETCH-LOGICAL-c758t-506e658d86cf163b4e1c36f938dfc01259997d80603ee9a05dee99fd4b33aed93</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4641684/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4641684/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,27901,27902,53766,53768,79342,79343</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/26559676$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Hirata, Kazuhito</creatorcontrib><creatorcontrib>Wake, Minoru</creatorcontrib><creatorcontrib>Takahashi, Takanori</creatorcontrib><creatorcontrib>Nakazato, Jun</creatorcontrib><creatorcontrib>Yagi, Nobuhito</creatorcontrib><creatorcontrib>Miyagi, Tadayoshi</creatorcontrib><creatorcontrib>Shimotakahara, Junichi</creatorcontrib><creatorcontrib>Mototake, Hidemitsu</creatorcontrib><creatorcontrib>Tengan, Toshiho</creatorcontrib><creatorcontrib>Takara, Tsuyoshi R</creatorcontrib><creatorcontrib>Yamaguchi, Yutaka</creatorcontrib><title>Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.
We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.
An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).
WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.</description><subject>Abdomen</subject><subject>Acute coronary syndromes</subject><subject>Acute Disease</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Aorta</subject><subject>Aortic Aneurysm - diagnosis</subject><subject>Aortic Aneurysm - physiopathology</subject><subject>Aortic dissection</subject><subject>Aortic Dissection - diagnosis</subject><subject>Aortic Dissection - physiopathology</subject><subject>Cardiology</subject><subject>Computed tomography</subject><subject>Confidence intervals</subject><subject>Coronary vessels</subject><subject>Development and progression</subject><subject>Diabetes Mellitus - diagnosis</subject><subject>Diabetes Mellitus - physiopathology</subject><subject>Diagnosis</subject><subject>Diagnosis, Differential</subject><subject>Diagnostic Errors</subject><subject>Differential diagnosis</subject><subject>Echocardiography</subject><subject>Electrocardiography</subject><subject>Emergency medical care</subject><subject>Emergency medical services</subject><subject>Emergency Service, Hospital - 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diagnosis</topic><topic>Hypertension - physiopathology</topic><topic>Life assessment</topic><topic>Male</topic><topic>Medical diagnosis</topic><topic>Medical imaging</topic><topic>Medical research</topic><topic>Middle Aged</topic><topic>Mortality</topic><topic>Multivariate Analysis</topic><topic>Pain - diagnosis</topic><topic>Pain - physiopathology</topic><topic>Patients</topic><topic>Physicians</topic><topic>Precision medicine</topic><topic>Prognosis</topic><topic>Quartiles</topic><topic>Retrospective Studies</topic><topic>Time Factors</topic><topic>Veins & arteries</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hirata, Kazuhito</creatorcontrib><creatorcontrib>Wake, Minoru</creatorcontrib><creatorcontrib>Takahashi, Takanori</creatorcontrib><creatorcontrib>Nakazato, Jun</creatorcontrib><creatorcontrib>Yagi, Nobuhito</creatorcontrib><creatorcontrib>Miyagi, Tadayoshi</creatorcontrib><creatorcontrib>Shimotakahara, Junichi</creatorcontrib><creatorcontrib>Mototake, Hidemitsu</creatorcontrib><creatorcontrib>Tengan, Toshiho</creatorcontrib><creatorcontrib>Takara, Tsuyoshi R</creatorcontrib><creatorcontrib>Yamaguchi, Yutaka</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Gale In Context: Opposing Viewpoints</collection><collection>Gale In Context: Science</collection><collection>ProQuest Central (Corporate)</collection><collection>Animal Behavior Abstracts</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Biotechnology Research Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Ecology Abstracts</collection><collection>Entomology Abstracts (Full archive)</collection><collection>Immunology Abstracts</collection><collection>Meteorological & Geoastrophysical Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Agricultural Science Collection</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Technology Research Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Technology Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Materials Science & Engineering Collection</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest One Sustainability</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>Agricultural & Environmental Science Collection</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Technology Collection</collection><collection>Natural Science Collection</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Materials Science Collection</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Materials Science Database</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Meteorological & Geoastrophysical Abstracts - 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Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hirata, Kazuhito</au><au>Wake, Minoru</au><au>Takahashi, Takanori</au><au>Nakazato, Jun</au><au>Yagi, Nobuhito</au><au>Miyagi, Tadayoshi</au><au>Shimotakahara, Junichi</au><au>Mototake, Hidemitsu</au><au>Tengan, Toshiho</au><au>Takara, Tsuyoshi R</au><au>Yamaguchi, Yutaka</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2015-11-11</date><risdate>2015</risdate><volume>10</volume><issue>11</issue><spage>e0141929</spage><epage>e0141929</epage><pages>e0141929-e0141929</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.
We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.
An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).
WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>26559676</pmid><doi>10.1371/journal.pone.0141929</doi><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1932-6203 |
| ispartof | PloS one, 2015-11, Vol.10 (11), p.e0141929-e0141929 |
| issn | 1932-6203 1932-6203 |
| language | eng |
| recordid | cdi_plos_journals_1732577134 |
| source | MEDLINE; DOAJ Directory of Open Access Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; PubMed Central; Free Full-Text Journals in Chemistry; Public Library of Science (PLoS) |
| subjects | Abdomen Acute coronary syndromes Acute Disease Aged Aged, 80 and over Aorta Aortic Aneurysm - diagnosis Aortic Aneurysm - physiopathology Aortic dissection Aortic Dissection - diagnosis Aortic Dissection - physiopathology Cardiology Computed tomography Confidence intervals Coronary vessels Development and progression Diabetes Mellitus - diagnosis Diabetes Mellitus - physiopathology Diagnosis Diagnosis, Differential Diagnostic Errors Differential diagnosis Echocardiography Electrocardiography Emergency medical care Emergency medical services Emergency Service, Hospital - statistics & numerical data Emergency vehicles Female Heart attacks Heart Failure - diagnosis Heart Failure - physiopathology Heart surgery Hospital emergency services Hospitals Humans Hypertension - diagnosis Hypertension - physiopathology Life assessment Male Medical diagnosis Medical imaging Medical research Middle Aged Mortality Multivariate Analysis Pain - diagnosis Pain - physiopathology Patients Physicians Precision medicine Prognosis Quartiles Retrospective Studies Time Factors Veins & arteries |
| title | Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room |
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