BMJ  2003;326:1134 (24 May), doi:10.1136/bmj.326.7399.1134

Commentary

Challenge for emergency physicians

¹ Department of Emergency Medicine, Vienna General Hospital, Währinger Gürtel 18-20, 1090 Vienna, Austria harald.herkner{at}akh-wien.ac.at

Aortic dissection is relatively rare,¹ but because patients may die rapidly doctors need to bear it in mind when patients present with chest pain. The likelihood of encountering a case of aortic dissection is higher in emergency departments than in primary care. In our department, located in a 2000 bed university hospital, we see about one patient a week with acute aortic disease.² The fact that most electronic responses to the first part of this case report mentioned aortic dissection among their differential diagnoses suggests that, in this select group at least, awareness is high.

Like Peter Hartl, most patients with aortic dissection are seriously ill and are unlikely to be discharged from hospital inappropriately. The key role of the emergency physician is therefore to make an early accurate diagnosis. Every hour of delay worsens the patient's prognosis by 1%.³ Mortality is about 50% within the first 48 hours if untreated.

Unfortunately, the symptoms and signs associated with aortic dissection may not be clear cut.⁴ The most important differential diagnosis is acute coronary syndrome, because treatment differs. Antithrombotic therapy, antiplatelet therapy, and thrombolysis are beneficial for acute coronary syndrome but harmful for aortic dissection. Furthermore, the prognosis in patients with acute coronary syndrome worsens with delayed therapy, especially if acute myocardial infarction is present. Diagnosis is particularly complicated if the two conditions coexist, which can occur if the dissection affects the coronary arteries. Pulmonary embolism is the second important differential diagnosis.

Swift differentiation between these three major diagnoses is crucial for appropriate management and a good outcome. An initial diagnostic workup including electrocardiography, chest radiography, transthoracic echocardiography, and measurement of troponins and D-dimer should help differentiate between the three diagnoses. Transoesophageal echocardiography, magnetic resonance imaging, or computed tomography will establish the diagnosis of aortic dissection.⁵

If aortic dissection, acute coronary syndrome, and pulmonary embolism are ruled out, there is a little more time to consider other important possible diagnoses such as perimyocarditis, pleurisy, pneumothorax, pancreatitis, gastroesophageal diseases, and musculoskeletal disorders. Respondents on bmj.com mentioned all of these as differential diagnoses.

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Competing interests: None declared.

References

1. 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;283: 897-903.[Abstract/Free Full Text]
2. Bayegan K, Domanovits H, Schillinger M, Ehrlich M, Sodek G, Laggner AN. Acute type A aortic dissection: the prognostic impact of preoperative cardiac tamponade. Eur J Cardiothorac Surg 2001;20: 1194-8.[Abstract/Free Full Text]
3. Hirst AE, Johns VJ, Kime SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37: 217-79.[Medline]
4. Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA 2002;287: 2262-72.[Abstract/Free Full Text]
5. Nienaber CA, von Kodolitsch Y, Nicolas V, Siglow V, Piepho A, Brockhoff C, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328: 1-9.[Abstract/Free Full Text]

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