Clinical scenario

A 52 year old man attends the emergency department with central chest tightness and left arm heaviness. ECG shows anterior ST elevation of 3 mm in three consecutive leads. He has a normal mediastinum on chest radiograph, but as you administer the thrombolytic agent, you wonder just how sensitive this investigation is in ruling out an aortic dissection.

Three part question

In a [patient with chest pain] what is the [sensitivity of a normal chest radiograph] in ruling out [aortic dissection]?

Search strategy

Medline 1966-11/03 using the OVID interface. [exp Aneurysm, Dissecting OR dissecti$.mp OR aneurysm.mp] AND [exp AORTA OR exp AORTA, THORACIC OR aort$.mp.] AND [X-ray.mp OR exp X-Rays OR exp Radiography, Thoracic OR radiograph$.mp] LIMIT to human AND English.

Search outcome

Altogether 557 papers were found. One recent literature review included the relevant papers with the exception of three additional papers (see table 2).

Comment(s)

All these studies are of poor quality. There is an enormous lack of quality prospective studies recruiting consecutive patients presenting to the emergency department with chest pain.

CLINICAL BOTTOM LINE

The classic chest radiological findings of a wide mediastinum or abnormal aortic contour do not seem sufficiently sensitive to rule out aortic dissection in a patient with chest pain.