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Aortic Dissection Misdiagnosed as Acute Coronary Syndromes: Presented at CCC

By Danny Kucharsky

MONTREAL, CANADA -- October 28, 2005 -- Aortic dissection is frequently confused with acute coronary syndromes by physicians, a mistake that often leads to use of the wrong treatment, with antiplatelet, antithrombotic, and even thrombolytic therapy, researchers report.

Both are rare but lethal conditions, with clinical and epidemiologic overlap. The difficulty in diagnosing acute aortic syndromes and the emphasis that is put on timeliness of treatment delivery in acute coronary syndromes are the main causes of the problem, investigators said.

At the Canadian Cardiovascular Society Congress 2005 (CCC), Stuart Hutchison, MD, cardiologist, intensive care unit, St. Michael's Hospital, Toronto, Ontario, Canada, presented study results on 68 sequential cases of acute aortic dissections admitted to a tertiary care hospital from January 2000 to December 2004.

In his presentation here on October 24^th, Dr. Hutchison said the researchers evaluated the incidence of incorrect initial diagnosis leading to treatment among the 63 dissections, 3 intramural haematomas, and 2 penetrating atherosclerotic ulcers. Subjects were identified by a review of surgical databases, critical care unit logbooks, and hospital discharge summaries. The researchers obtained outcomes, investigations, and interventions from hospital charts and electronic records.

The analysis shows that an incorrect initial diagnosis leading to treatment occurred in 40% of 68 cases with acute aortic syndromes, most of which were thought to be acute coronary syndromes. Heparin was administered in 32% of cases, aspirin in 40%, clopidogrel in 1%, and a fibrinolytic in 4%.

Initial misdiagnosis was associated with longer mean time to correct diagnosis (15 hours vs 53 hours, P = .006), but not with an increased number of diagnostic tests, Dr. Hutchison said.

The increased availability of anticoagulants for the treatment of acute coronary syndromes has only increased the potential hazards of inadvertent treatment, he said.

Treatment with anticoagulants was associated with increased incidence of haemorrhagic pericardial fluid (48% vs 24%, P = .04) and haemodynamic instability prior to definitive intervention (29% vs 12%, P = .09). Postoperative complications increased significantly following anticoagulant treatment, including massive haemorrhage (36% vs 12%, P = .03) and reoperation for bleeding (39% vs 17%, P = .04). Postoperative complications did not increase significant the mortality rate, however (23% vs 12%, P = ns).

Given the risks of delayed diagnosis and clinically significant bleeding as a result of inappropriate treatment with antiplatelet, anticoagulant, and fibrinolytic agents, Dr. Hutchison said management of acute coronary syndromes should emphasize diagnosis and exclusion of acute aortic syndromes.


[Presentation title: Recognition and Management of Aortic Dissection: Frequency and Consequences of Inadvertent Treatment With Antiplatelet, Antithrombolytic Agents, Abstract 356]

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