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ENDGAMES: Radhakrishnan Ramaraj Sudden onset of headache and recent breathlessness BMJ 2008; 337: a1844 [Full text]

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overinvestigation can lead to diagnostic delay

oscar,m jolobe   (21 November 2008)

overinvestigation can lead to diagnostic delay 21 November 2008
oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP Send response to journal: Re: overinvestigation can lead to diagnostic delay	When the presenting symptoms and signs of aortic dissection are typical, and include chest pain, dyspnoea, aortic regurgitation, and inter -arm discrepancies in blood pressure in a hypertensive patient, there should be no delay in implementing strategies to confirm the diagnosis, even though there may be unusual associated symptoms such as headache(1). The association of headache and dyspnoea is common to subarachnoid haemorrhage(SAH) and to aortic dissection, and the overlap in clinical features between the two disorders is compounded by the fact that they also share stigmata such as elevation in serum troponin levels(2), and "ischaemic" electrocardiographic(ECG) abnormalities(3). Accordingly, laboratory tests such as serum troponin, intended to "narrow the differential diagnosis toward aortic dissection"(1) may, if positive, have the unintended consequence of leading one up a diagnostic "blind alley", thereby potentially causing delay in starting treatment. Likewise D-dimer testing, given the fact that the association of D-dimer positivity and recent-onset dyspnoea is common to aortic dissection and to pulmonary embolism(4). Given the fact that few patients can tolerate therapeutic delay attributable to "sojourn" in a diagnostic "blind alley", clinicians ought to recognise what the risk factors are for diagnostic delay. According to a recent study, those factors include troponin positivity(Odds Ratio 3.63, 95% Confidence Interval 1.12 to 11.84), "acute coronary syndrome-like" ECG abnormalities(Odds Ratio 2.88, CI 1.01 to 8.17), and pleural effusion(Odds Ratio 3.96, CI 1.80 to 8.69)(5). Accordingly, when aortic dissection is clinically the most likely diagnosis, even when there are additional symptoms which are atypical, we must be careful not to stray into blind alleys which may not only delay the eventual diagnosis, but may also lead to inappropriate and potentially dangerous therapeutic decisions. References (1)Ramaraj R Sudden onset of headache and recent breathlessness British Medical Journal 2008;337:a1844 (2)Tanabe M., Crago EA., Suffoletto M et al Relation of elevation in cardiac troponin I to clinical severity, cardiac dysfunction, and pulmonary congestion in patients with subarachnoid hemorrhage American Journal of Cardiology 2008;102:1545-1550 (3) Sugimoto K., Watanabe E., Yamada A et al Prognostic implications of left ventricular wall motion abnormalities associated with subarachnoid hemorrhage International Heart Journal 2008;49:75-85 (4) Jolobe OMP Potentially dangerous diagnostic pitfalls arise from diagnostic tests(letter) British Medical Journal 2006;332:364 (5) Rapezzi C., Longhi S., Graziosi M et al Risk factors for diagnostic delay in acute aortic dissection American Journal of Cardiology 2008;102:1399-1406 Competing interests: None declared