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Peripheral pulses to exclude thoracic aortic dissection
  1. Stewart Teece, Clinical Research Fellow,
  2. Kerstin Hogg, Clinical Research Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jonesman.ac.uk

    Abstract

    A short cut review was carried out to establish whether the absence of a clinical pulse deficit can be used to exclude dissecting thoracic aneurysm in patients with chest pain. Altogether 89 papers were found using the reported search, of which one was a previous systematic literature review. A further two papers published since the review were also found. These three papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

    • thoracic aortic dissection

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    Report by Stewart Teece,Clinical Research FellowChecked by Kerstin Hogg, Clinical Research Fellow

    Clinical scenario

    A 63 year old man presents to the emergency department with a one hour history of central chest pain of sudden onset. ECG shows ST elevation in his inferior leads. He has no obvious contraindications to thrombolysis in his history but you wish to ensure he has no evidence of a dissecting thoracic aneurysm before giving streptokinase. To keep your door to needle time below 20 minutes you wonder whether excluding a pulse deficit clinically is sensitive enough to avoid waiting for radiography.

    Three part question

    In [patients with acute chest pain] what [is the sensitivity of abnormal peripheral pulses] for [diagnosing acute dissection of the thoracic aorta]?

    Search strategy

    Medline 1966-05/04 using the Ovid interface. ([disect$.af. OR dissect$.af] AND [aorta.af OR aortic.af] AND [thoracic.af OR chest.af OR thorax.af OR ascend$.af OR arch.af OR descend$.af] AND [pulse.af OR puls$.af]) LIMIT to human AND English language

    Search outcome

    Altogether 89 papers found. One was a systematic review of the literature up to 2000. All relevant papers except two that post-dated it were included in this review. These three papers are summarised in the table 3.

    Table 3

    Comment(s)

    Few studies use a control group and use a top-down approach of assessing only patients with a dissection. This makes calculation of likelihood ratios difficult. There is yet to be a blinded bottom up trial of pulse deficit in thoracic aorta dissection. Interestingly it appears that pulse deficit may have use in the risk assessment of dissection.

    CLINICAL BOTTOM LINE

    Pulse deficit has a sensitivity of around 30% in dissecting thoracic aortic aneurysm. This is far too low to be considered suitable as a SnOut and other investigations are required.

    Report by Stewart Teece,Clinical Research FellowChecked by Kerstin Hogg, Clinical Research Fellow

    References

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