Abstract：
BACKGROUND: The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. We describe characteristics of ED attendances with symptoms potentially associated with AAS, diagnostic performance of clinical decision tools (CDTs) and physicians and yield of CT aorta angiogram (CTA).
METHODS: This was a multicentre observational cohort study of adults attending 27 UK EDs between 26 September 2022 and 30 November 2022, with potential AAS symptoms: chest, back or abdominal pain, syncope or symptoms related to malperfusion. Patients were preferably identified prospectively, but retrospective recruitment was also permitted. Anonymised, routinely collected patient data including components of CDTs, was abstracted. Clinicians treating prospectively identified patients were asked to record their perceived likelihood of AAS, prior to any confirmatory testing. Reference standard was radiological or operative confirmation of AAS. 30-day electronic patient record follow-up evaluated whether a subsequent diagnosis of AAS had been made and mortality.
RESULTS: 5548 patients presented, with a median age of 55 years (IQR 37-72; n=5539). 14 (0.3%; n=5353) had confirmed AAS. 10/1046 (1.0%) patients in whom the ED clinician thought AAS was possible had AAS. 5/147 (3.4%) patients in whom AAS was considered the most likely diagnosis had AAS. 2/3319 (0.06%) patients in whom AAS was considered not possible did have AAS. 540 (10%; n=5446) patients underwent CT, of which 407 were CTA (7%). 30-day follow-up did not reveal any missed AAS diagnoses. AUROC (area under the receiver operating characteristic) curve for ED clinician AAS likelihood rating was 0.958 (95% CI 0.933 to 0.983, n=4006) and for individual CDTs were: Aortic Dissection Detection Risk Score (ADD-RS) 0.674 (95% CI 0.508 to 0.839, n=4989), AORTAs 0.689 (95% CI 0.527 to 0.852, n=5132), Canadian 0.818 (95% CI 0.686 to 0.951, n=5180) and Sheffield 0.628 (95% CI 0.467 to 0.788, n=5092).
CONCLUSIONS: Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer.
BACKGROUND: NCT05582967; NCT05582967.
METHODS: This was a multicentre observational cohort study of adults attending 27 UK EDs between 26 September 2022 and 30 November 2022, with potential AAS symptoms: chest, back or abdominal pain, syncope or symptoms related to malperfusion. Patients were preferably identified prospectively, but retrospective recruitment was also permitted. Anonymised, routinely collected patient data including components of CDTs, was abstracted. Clinicians treating prospectively identified patients were asked to record their perceived likelihood of AAS, prior to any confirmatory testing. Reference standard was radiological or operative confirmation of AAS. 30-day electronic patient record follow-up evaluated whether a subsequent diagnosis of AAS had been made and mortality.
RESULTS: 5548 patients presented, with a median age of 55 years (IQR 37-72; n=5539). 14 (0.3%; n=5353) had confirmed AAS. 10/1046 (1.0%) patients in whom the ED clinician thought AAS was possible had AAS. 5/147 (3.4%) patients in whom AAS was considered the most likely diagnosis had AAS. 2/3319 (0.06%) patients in whom AAS was considered not possible did have AAS. 540 (10%; n=5446) patients underwent CT, of which 407 were CTA (7%). 30-day follow-up did not reveal any missed AAS diagnoses. AUROC (area under the receiver operating characteristic) curve for ED clinician AAS likelihood rating was 0.958 (95% CI 0.933 to 0.983, n=4006) and for individual CDTs were: Aortic Dissection Detection Risk Score (ADD-RS) 0.674 (95% CI 0.508 to 0.839, n=4989), AORTAs 0.689 (95% CI 0.527 to 0.852, n=5132), Canadian 0.818 (95% CI 0.686 to 0.951, n=5180) and Sheffield 0.628 (95% CI 0.467 to 0.788, n=5092).
CONCLUSIONS: Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer.
BACKGROUND: NCT05582967; NCT05582967.
摘要：
背景：急性主动脉综合征（AAS）的诊断通常在ED中延迟或漏诊。我们描述了ED出勤率的特征，这些症状可能与AAS相关，临床决策工具（CDT）和医师的诊断性能以及CT主动脉造影（CTA）的产量。
方法：这是一项多中心观察性队列研究，研究对象为2022年9月26日至2022年11月30日期间参加27个英国ED的成年人，其潜在的AAS症状：胸部，背部或腹部疼痛，晕厥或与灌注不良有关的症状。最好是前瞻性地确定患者，但也允许回顾性招募。匿名，常规收集患者数据，包括CDT的组成部分，是抽象的。治疗前瞻性识别患者的临床医生被要求记录他们感知的AAS可能性，在进行任何确认测试之前。参考标准是AAS的放射学或手术确认。30天的电子患者记录随访评估是否已做出AAS的后续诊断和死亡率。
结果：5548例患者，年龄中位数为55岁（IQR37-72；n=5539）。14（0.3%；n=5353）已确认AAS。10/1046（1.0％）ED临床医生认为可能存在AAS的患者患有AAS。5/147(3.4%)AAS被认为是最有可能诊断的患者患有AAS。2/3319（0.06％）被认为不可能进行AAS的患者患有AAS。540例（10％；n=5446）患者接受了CT检查，其中CTA407例（7%）。30天的随访没有发现任何错过的AAS诊断。ED临床医生AAS可能性评级的AUROC（受试者工作特征下面积）曲线为0.958（95％CI0.933至0.983，n=4006），个体CDT为：主动脉夹层检测风险评分（ADD-RS）0.674（95％CI0.508至0.839，n=4989），AORTAs0.689（95%CI0.527至0.852，n=5132），加拿大0.818（95%CI0.686至0.951，n=5180）和谢菲尔德0.628（95%CI0.467至0.788，n=5092）。
结论：仅0.3%的有潜在AAS症状的患者有AAS，但7%的患者有CTA。结合临床医生完形的CDT似乎最有前途，但是需要进一步的前瞻性工作，包括D-二聚体的作用评价。
背景：NCT05582967;NCT05582967。
方法：这是一项多中心观察性队列研究，研究对象为2022年9月26日至2022年11月30日期间参加27个英国ED的成年人，其潜在的AAS症状：胸部，背部或腹部疼痛，晕厥或与灌注不良有关的症状。最好是前瞻性地确定患者，但也允许回顾性招募。匿名，常规收集患者数据，包括CDT的组成部分，是抽象的。治疗前瞻性识别患者的临床医生被要求记录他们感知的AAS可能性，在进行任何确认测试之前。参考标准是AAS的放射学或手术确认。30天的电子患者记录随访评估是否已做出AAS的后续诊断和死亡率。
结果：5548例患者，年龄中位数为55岁（IQR37-72；n=5539）。14（0.3%；n=5353）已确认AAS。10/1046（1.0％）ED临床医生认为可能存在AAS的患者患有AAS。5/147(3.4%)AAS被认为是最有可能诊断的患者患有AAS。2/3319（0.06％）被认为不可能进行AAS的患者患有AAS。540例（10％；n=5446）患者接受了CT检查，其中CTA407例（7%）。30天的随访没有发现任何错过的AAS诊断。ED临床医生AAS可能性评级的AUROC（受试者工作特征下面积）曲线为0.958（95％CI0.933至0.983，n=4006），个体CDT为：主动脉夹层检测风险评分（ADD-RS）0.674（95％CI0.508至0.839，n=4989），AORTAs0.689（95%CI0.527至0.852，n=5132），加拿大0.818（95%CI0.686至0.951，n=5180）和谢菲尔德0.628（95%CI0.467至0.788，n=5092）。
结论：仅0.3%的有潜在AAS症状的患者有AAS，但7%的患者有CTA。结合临床医生完形的CDT似乎最有前途，但是需要进一步的前瞻性工作，包括D-二聚体的作用评价。
背景：NCT05582967;NCT05582967。
