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).
Conclusion 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.
- emergency department
- computed tomography
- diagnostic tests
Data availability statement
Data are available upon reasonable request. All study data and metadata will be available upon reasonable request to firstname.lastname@example.org.
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Handling editor Richard Body
Collaborators On behalf of the DAShED investigators * (co-applicants, site principal investigators and study teams): DAShED Co-Applicants: Catherine Fowler (The Aortic Dissection CharitableTrust (TADCT)); Ben Loryman (Sheffield Teaching Hospitals NHS FT); Graham Cooper (The Aortic Dissection Charitable Trust (TADCT)); Rob Hirst (Trainee Emergency Research Network (TERN)); Robert Hinchliffe (University of Bristol); Steven Thomas (Sheffield Teaching Hospitals, NHS Foundation Trust). DAShED Site Principal Investigators: Benjamin Clarke (Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK); Edd Carlton (North Bristol NHS Trust); Alasdair Corfield (Royal Alexandra Hospital, NNHS Greater Glasgow and Clyde); David Lowe (Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde); Angelo Giubileo (Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn); Rajendra Raman (Victoria Hospital Kirkcaldy); Oliver McNab (Manchester Royal Infirmary, Wythenshawe Hospital, Manchester University NHS FT); Amir Guirguis (James Paget University Hospital NHS Foundation Trust); Mark Mitchelson (Raigmore, Inverness); Punithan Annamalai (Harrogate hospital); Deon Louw (John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Horton Hospital, Oxford University Hospitals NHS Foundation Trust); Patrick Aldridge (Frimley Park Hospital, Frimley Health NHS Foundation Trust); Sarah Wilson (Wexham Park Hospital, Frimley Health NHS Foundation Trust); Salini Zaini (Royal Berkshire NHS Foundation Trust); Valentino Oriolo (Bristol Royal Infirmary); Manoj Viegas (Bedfordshire Hospitals NHS Foundation Trust; Luton &Dunstable University Hospital); Steve Goodacre (Sheffield Teaching Hospitals NHS Foundation Trust); Dr Divyansh Gulati (Milton Keynes University Hospital NHS Foundation Trust); Susie Hardwick (Addenbrookes); Mayukhmoy Maiti (Royal Glamorgan Hospital, Cwm Taf Morgannwg University health board); Dr Hamzah Azzam (Hywel Dda University Health Board); Graham Johnson (University hospitals of Derby and Burton NHS Foundation Trust); Larisa Chirila (Kettering General Hospital). DAShED Site Study Teams: Rachel McLatchie, Matt Reed, Nicola Freeman, Alicia Cowan, Benjamin Clarke, Salma Alawiye, Thomas Cox, Joe Sharpe, Harriet Jennings, Rosie Andrews, Lorenzo Zucchelli, Evie Picton, YsabelleThackray, Fiona Allan, Hanmo Zhang, Clare Moceivei, Sam Covins, Alba Garcia-Mendelez, Amina Kaddouri, Thomas Connor, Ellen Voute, Kathryn Greenslade, Adam Stanley, Eilish Murphy, Ciaran Gunn, Harriet Cole (Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK); Ed Carlton, Nicola Maivel, Sanjay Patel, Emma Mullen, Lucy Rivers, James Foley, Nima Maleki, Jessica Hughes, Sophia Reynolds, Sinead Brady, Rosemarie Bird, Harry Quin, Ruth Cockburn, Karthikeyini Suresh (North Bristol NHS Trust, Bristol, UK); Alasdair Corfield, Natalie Rodden, Lynn Abel, Susan Currie, Rachel Keen, Natasha Parker (Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, UK); David Lowe, Elisha Khoo, Kareem Austin, Rhys Worgan, Malcolm Gordon, Mark Wilson, Kayleigh Doran, Ornagh O'Shaughnessy, Lisa Finnen, Courtney Mcarthur (Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, UK); Ayesha Malik, Bhaskar Sarvesh, Fatima Ismail, Jarno Holopainen, Joanna Rudnika, Mohamed Nasr, Oluwaseyi Okewole, Saranya Kathrivel, Wickramanayake Udara, Mohamed Imam, Angelo Giubileo, Tracey Fuller, Hammed Tiamiyu (Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn, Norfolk, UK); Rajendra Raman, Saqib Parwez, Keith Boath, Heather Robertson, Amy McCallum, Kyle McLachlan, Naomi Gunn, Cristina Sifiringa, Claire Stewart, Jennifer Wood, Rhys Greig (Victoria Hospital, Kirkcaldy, Fife, UK); Anila Sukumaran, Charlotte Taylor, Melanie Barker, Richard Clark, Deborah Paripoorani, Rose Jama, Oliver McNab, Agnieszka Rozanska, Melanie Barker, Dr Govind Oliver (Manchester Royal Infirmary and Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK); Amir Guirguis, Dr Magdi Mohammed, Dr Likaa Gabr, Dr Katie Landles, Dr Favour Balogun, Dr Rafiq Abdul,Helen Sutherland, Charlotte Kelly (James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK); Mark Mitchelson, Emuyemiken Egwuelu, Fiona Barrett (Raigmore, Inverness, UK); Punithan Annamalai, Caroline Bennett, Cheryl McDermott, Joyce Guy (Harrogate Hospital, North Yorkshire, UK); Deon Louw, Alex Novak, Alexis Espinosa, Gianni Tam-McMillan, Antoni Krupa, Tabitha Thorton-Swan, Sophie Roberts, Samuel Mills, Abdala Trinidad Espinosa-Morgado, Sally Beer, Elizabeth Hatton, Georgy Corby, Iris Mae Morse, Lauren Scullion, Ayan Shahid, Jessy Jindal, Aisling Curtis, Jessica Morgan, Joseph Layzell (John Radcliffe, Oxford, UK, Horton Oxford University Hospitals NHS Foundation Trust, UK); Patrick Aldridge, Sana Nadeem, Shalini Ravishankar, Hannily Cooke, Jodie Clarke, Jaskiran Dulai, Sinead Helyar, Myra Dinglasan, Durga Ponnaganti (Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK); Sarah Wilson, Joana Da Rocha, Karen Chivers, Francoise Ticehurst, Louise Gardner, Vani Muthusami, Marie Broyde, Zoe Foster, Nattakarn Limphaibool, Victoria Tay, Shihana Saifudheen, Arane Prabakaran, Shahab Manouchehri, Faluade Akinroye, Rahul Shah, Joseph Mahony, Amrit Gherra, Rob Conway (Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK); Liza Keating, Salini Zaini, Emma Grierson, Shauna Bartley,Nicola Jacques, Giulia Mascia, Francesca Compton, Gabriela Tomkova, Sabi Rai, Kuldeep Nijjar, Edward Neary, Jonathon Lane, Kin Yung Lam, Mohammed Albakoush, Tejas Harit, Silvia Panetta, Mae Gill, Carmen Powell, Erin Robinson, Helen Callard, Hameed Qureshi, Hira Naeem, Laura Hudson, Osama Akrama (Royal Berkshire NHS Foundation Trust, Reading, UK); Emma Redfern, Casandra Bazanlacerot, Rachel Shiel, Christina Coleman, Eva Maria Hernandez Morano, Eleanor Daniel, Kim Wright, Catherine Macleodhall, Denise Webster, Valentino Oriolo, Katie Sweet, Josie Bonnici, Irene Grossi, Carl Robinson, Omar Almousa, Jonathan Benger (Bristol Royal Infirmary, Bristol, UK); Manoj Viegas, Charlotte Whitehouse, Leigh Bissett, Fredrico Miranda, Dinkar Bisht (Bedfordshire Hospitals NHS Foundation Trust; Luton & Dunstable University Hospital, UK); Steve Goodacre, Hannah Walker, Jaden Groves, John Banner, Sayantani Mukhopadhyay, Yasmin Mahmud, Charles Wong, Shamiso Muza, Oliver Salwey (Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK); Divyansh Gulati, Hina Tahir, Santos Oshiotes, Devika Chaudhri, Wuraola Akande (Milton Keynes University Hospital NHS Foundation Trust, UK); Susie Hardwick, Katie Coupe (Addenbrooke’s Hospital, Cambridge, UK); Lisa Roche, Mayukhmoy Maiti, Eleanor James (Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, UK); Hamza Azzam, Janet Phipps, Catherine MacPhee, Michelle Edwards, Hannah Blowing, Samantha Coetzee, Lucy Hill, Jill Williams, Becky Icke, Bethan Landeg, Helen Tench, Heather McGuinness, Tanya Sims, Rebecca Wolf-Roberts, Ronda Loosley, Maddie Moores, Kimberley Walker (Hywel Dda University Health Board, (Withybush, Bronglais, Glagwilli), UK); Elisha Cousins, Graham Johnson, Alison Rockey, Alison Fletcher, Lianne Wright, Lucy-May Moulden, Tom Ward, Andrew Tabner, Sarah Allen, Hannah Phillips, Obiageli Ngwuocha (University Hospitals of Derby and Burton NHS Foundation Trust, UK); Larisa Chirila, Hannah Britton, Julimon Sebastian, John Obiakor, Nathan Hancock (Kettering General Hospital, Northamptonshire, UK).
Contributors RM, MJR, NF, RAP, SW, SG, AC, JB, BC and EC conceived the study and were involved in study design and study delivery. MJR and RAP performed data analysis. RM, MJR, NF, RAP, SW, SG, AC, JB, BC and EC were involved in data interpretation and RM, MJR, NF, RAP, SW, SG, AC and EC prepared the manuscript. RM, MJR, NF, RAP, SW, SG, AC, JB, BC and EC contributed to its revision. MJR takes responsibility for the paper as a whole and acts as guarantor, accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish. The DAShED investigators were involved in the acquisition of data for the work.
Funding This study was supported by a Royal College of Emergency Medicine (RCEM) research grant. MJR is supported by an NHS Research Scotland Career Researcher Clinician award.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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