This is a retrospective look at 109 cases eventually diagnosed with aortic dissection – with a focus on the differentiating clinical features present in the 17 cases where the diagnosis was initially missed in the Emergency Department.
Confounding clinical attributes that were associated with a missed diagnosis were walk-in vs. ambulance arrival and presence of anterior chest pain. Chest x-rays lacking a wide mediastinum were nonsignificantly associated with missed aortic dissection, and with only 55% of their diagnosis cohort having a wide mediastinum vs. 25% of their misdiagnosis cohort. Interestingly, over 75% of each group received a d-Dimer and they were all positive in the misdiagnosis group as well as all but one in the diagnosis group. It would seem that they order so many d-Dimers that they’ve become fatigued to its clinical usefulness due to its poor specificity.
The good news is the patients who were initially misdiagnosed had similar mortality (18% vs. 15%) – despite 7 of the 17 being treated with antithrombotic agents. Most of the missed diagnoses were classified as undifferentiated possible ischemic chest pain, but two were diagnosed with renal colic.
As always, the main problem with missed-diagnosis literature is there’s no guarantee the authors didn’t miss another set of cases themselves.
“Factors leading to failure to diagnose acute aortic dissection in the emergency room.”
www.ncbi.nlm.nih.gov/pubmed/21889877