Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain

A retrospective cohort study and chart review were performed to estimate the absolute and relative prevalence of the serious diagnoses that might cause a patient to present to the Emergency Department (ED) with a chief complaint of chest pain. In this study, we queried a database of 347,229 complete visits to the San Francisco General Hospital Emergency Department between July 1, 1993 and June 30, 1998 for visits by patients > 35 years old with a chief complaint of chest pain and no history of trauma. Visits for chest pain that resulted in hospitalization were assigned to one of nine diagnostic groups according to final diagnoses as coded in the database. Manual chart review by trained abstractors using explicit criteria was done when group assignment based on coded diagnoses was unclear and in all diagnoses of pulmonary embolism and aortic dissection. Of 8711 visits (2.5% of all visits) with a chief complaint of non-traumatic chest pain, 3271 (37.6%) resulted in hospitalization. Of the 3078 (94.1% of those hospitalized) assigned a final diagnosis, 329 (10.7% of hospitalizations, 3.8% of all visits) had acute myocardial infarction, 693 (22.5%) had either unstable angina or stable coronary artery disease, and 345 (11.2%) had pulmonary causes (mainly bacterial pneumonia) deemed serious enough to require hospitalization. Pulmonary embolism and aortic dissection were diagnosed in only 12 (0.4%) and 8 (0.3%) patients, respectively. In 905 (29.4%) hospitalizations for chest pain, myocardial infarction was “ruled out” and no cardiac ischemia or other serious etiology for the chest pain was diagnosed. Among patients presenting with chest pain, those in older age groups had dramatically increased risk of acute myocardial infarction. Women presenting with chest pain had a lower risk of acute myocardial infarction than men. In conclusion, the prevalence of acute myocardial infarction in the undifferentiated ED patient with a chief complaint of chest pain is only about 4%. An equal number of patients will have a serious pulmonary cause as the etiology of their pain. Pulmonary embolism and aortic dissection are important but extremely rare causes of a chest pain presentation to the ED.     

Painless aortic dissection presenting with acute ischaemic stroke and multiple organ failure

Acute aortic dissection is an uncommon, life‐threatening catastrophe, and early diagnosis is essential for the best chance of survival. Although acute onset of severe chest or back pain is the most common presenting symptom, some patients might present with atypical symptoms and findings such as acute stroke and mesenteric ischaemia related to the involving arterial segment. Establishing the diagnosis of aortic dissection can be difficult in the presence of atypical symptoms, especially in the absence of pain. Here, we report a case of acute, painless aortic dissection presenting with multiple organ failure and neurological deficits suggesting acute ischaemic stroke.     

Aortic dissection presenting as uniocular blindness

A patient presented with uniocular blindness and headache, which was initially suspected to be subarachnoid hemorrhage. The patient had a seven-year history of diabetes mellitus, hypertension and hypothyroidism, as well as a two-year history of congestive cardiac failure with aortic regurgitation. Upon autopsy, the patient was diagnosed with aortic dissection. There are no other known reports of such a presentation. This case demonstrates that aortic dissection can present without any classical features, and hence it is important to consider the possibility of dissection in patients with long-standing hypertension and acute neurologic symptoms associated with pain.     

Chronic Aortic Dissection in a Young Adult

Background: Acute aortic dissection is a life-threatening disease that is often a diagnostic challenge in the Emergency Department (ED). Patients with acute aortic dissection often have underlying hypertension and atherosclerotic disease, and commonly present with acute-onset severe chest or back pain in their sixth or seventh decades of life. Aortic dissection, however, can also be seen in patients < 40 years old and may present chronically, with symptom duration longer than 2 weeks. Objective: We present an unusual case of chronic aortic dissection in a young patient, followed by a review of the literature on chronic aortic dissections and aortic dissections in young patients. Case Report: We report a case of chronic aortic dissection in a 32-year-old man with a history of untreated hypertension who presented to the ED with palpitations and mild shortness of breath. Conclusion: Acute and chronic thoracic aortic dissections can occur in patients of all ages, as well as in patients with atypical signs and symptoms.     

Acute thoracic aortic dissection: The basics

With an increasing incidence, aortic dissection is the most common acute illness of the aorta. In the setting of chronic hypertension, with or without other risk factors for aortic dissection, this diagnosis should be considered a diagnostic possibility in patients presenting to the emergency department with acute chest or back pain. Left untreated, about 75% of patients with dissections involving the ascending aorta die within 2 weeks of an acute episode. But with successful initial therapy, the 5-year survival rate increases to 75%. Hence, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome in a majority of the patients. This article reviews acute thoracic aortic dissection, including ED diagnosis and management.     

Coronary computed tomography angiography for the assessment of chest pain: current status and future directions

Chest pain is one of the most common presenting symptoms leading to presentation to medical clinics and Emergency Departments worldwide. Defining the nature and etiology of chest pain can pose a diagnostic dilemma for clinicians, despite the availability of several diagnostic algorithms and guidelines to assist them in evaluating these patients. Most investigations in patients with acute chest pain are initially performed to either exclude or diagnose and manage potentially life-threatening conditions such as acute coronary syndrome, pulmonary embolism and aortic dissection. In cases of stable chest pain syndromes, the focus shifts to determining the presence, extent and severity of coronary artery disease. In recent years, coronary computed tomography angiography (CCTA) is being increasingly used worldwide in the assessment of both stable and acute chest pain syndromes. This review evaluates the current evidence regarding the clinical utility of CCTA in the stable and acute chest pain settings and outlines the latest advances in CCTA techniques, including functional assessment of coronary stenoses, and their potential clinical application to improve patient care in a cost-effective manner.     

Acute aortic dissection with painless paraplegia: report of 2 cases

Acute aortic dissection is often a life-threatening event that usually presents as a sudden, severe, exquisitely painful, ripping sensation in the chest or back. There are a few reports of atypical findings or no pain in the literature. We report 2 patients with painless acute aortic dissection who presented to the emergency department (ED) with sudden onset paraplegia.     

Thoracic aortic dissection in an 18-year-old woman with no risk factors

Spontaneous aortic dissection is a rare, life-threatening cause of chest pain, and has a higher prevalence when traditional risks such as age, hypertension, dyslipidemia, or connective tissue disorders are present. However, even in the absence of risk factors, non-traumatic rupture of an aortic dissection may occur. Most are found in patients over 40 years of age. Younger victims of this disease often also suffer from other conditions such as cystic medial necrosis, connective tissue disorders such as Marfan's syndrome, or vasculitis. We present the case of an 18-year-old, previously healthy woman who was country line dancing when she began to complain of severe, cramping chest and back pain. She was hemodynamically stable on initial presentation but experienced two seizures while in the emergency department and was intubated. Subsequently, her blood pressure dropped and she developed cardiac arrest, and despite vigorous resuscitation that included blood products and emergency department thoracotomy, she was refractory to all attempts. At autopsy she was found to have a spontaneous, non-traumatic rupture of an aortic dissection. This patient had no discernable risk factors for aortic dissection or discoverable cause on necropsy. We present this case to raise awareness among physicians and review other reported cases in the literature of aortic dissection in patients under age 40 years.     

Evaluation of Acute Chest Pain in the Emergency Department: Utility of Multidetector Computed Tomography

Distinguishing insignificant from life-threatening causes of acute chest pain in patients who present to the emergency department remains a major challenge. Initial evaluation with history, electrocardiography, and biochemical markers is often unrevealing leading to additional workup. Radionuclide perfusion and echocardiography may be diagnostic but provide only indirect assessment of coronary status. The development of multidetector computed tomography (MDCT) and its increasingly frequent placement near the emergency suite has facilitated its use for the evaluation of serious noncardiac diagnoses such as pulmonary embolism and aortic dissection. Recent innovations in MDCT technology have facilitated the depiction of coronary arteries. These advances have led to the possibility of using CT to evaluate cardiac etiologies of chest pain, using either a comprehensive or triple rule out protocol to assess both cardiac and noncardiac causes or a dedicated coronary protocol. This article will review both options and describes our preliminary experience with the first of these protocols. The article also reviews the potential value of an acute chest pain CT protocol and the considerable challenges that remain prior to its implementation for routine clinical use.     

Painless aortic dissection presenting as high paraplegia: a case report

Acute aortic dissection is a catastrophic episode that usually presents as a sudden, painful, ripping sensation in the chest or back. Physical findings may include loss of pulses and aortic regurgitation. It is associated with neurologic sequelae in as many as one third of patients. Painless dissection occurs in 5% of patients. We report a case of painless aortic dissection, presenting as acute paraplegia. The patient was a 77-year-old woman who presented with paraplegia, with no chest or back pain. On examination, strength was 5/5 in both upper extremities and 0/5 in both lower extremities. Deep tendon reflexes were absent in her legs. She had no voluntary anal contraction. Sensation was absent from T6 through S5. Computed tomography of the chest revealed a type A dissecting aneurysm. The vascular supply to the spinal cord and the differential diagnosis for new onset paraplegia are discussed.     

Spontaneous celiac artery dissection

BackgroundSpontaneous celiac artery dissection is a rare visceral artery dissection that typically presents with acute abdominal or flank pain.Case reportWe describe a case of a 54-year old previously healthy male who presented to the Emergency Department with subacute back pain and was found to have a spontaneous celiac artery dissection.Why should an emergency physician be aware of this?Emergency medicine physicians frequently consider acute aortic dissection in patients presenting to the Emergency Department with acute chest, back, and/or upper abdominal pain. Less commonly thought of are variations of arterial dissection, including those involving the celiac artery. Given readily available diagnostic imaging modalities and therapeutic interventions, it remains important to consider visceral arterial dissection, and to recognize the varied clinical manifestations of this rare clinical entity.     

Ischemic stroke with left hemiparesis or shock should be evaluated by computed tomography for aortic dissection

An 82-year-old woman with consciousness disturbance, left hemeparesis, and dysarthria was discovered at home by her family and was transported to a hospital. On arrival, she remained in a sleepy and disorientated and shock state. She complained of nausea but no chest or back pain. She obtained stable circulation after infusion. Her chest roentgen results showed widening of the mediastinum and the existence of a separation of the intimal calcification from the outer aortic soft tissue border, thus suggesting a Stanford A–type aortic dissection. Her head computed tomography depicted no signs of cerebral infarction. Because she did not complain of any pain, the possibility of acute phase aortic dissection was rejected. A permissive hypertensive therapy was initiated. Next day, she suddenly died. We diagnosed that she had died of a Stanford A–type aortic dissection based on the following facts: (1) patients presenting with stroke due to a Stanford A–type aortic dissection tend to have left hemiparesis because of malcirculation of the innominate artery and (2) a patient presenting with stroke by aortic dissection may have hypotension, which is unusual in standard stoke cases. Ischemic stroke induced by aortic dissection is not common among the patients with aortic dissection. However, given the high morbidity and mortality after misdiagnosis of aortic dissection, patients with ischemic stroke with left hemiparesis or shock should be evaluated by enhanced truncal computed tomography.     

Headache as a manifestation of a life-threatening vascular disorder

Headache is a common complaint among patients seeking medical assistance. The differentiation between a primary headache disorder versus headache as a symptom of a serious underlying disease is of crucial importance. Dissections of the carotid or vertebral arteries frequently present with headache and can result in ischemic stroke. Rarely, headache or neck pain is a presenting symptom in patients with spontaneous proximal aortic dissection. We report on a 53-year-old man with a history of migraine with aura, who was admitted to the hospital because of severe frontal headache and neck pain. An anterior chest pain lasting for 10 minutes the day before and a diastolic heart murmur suggested a proximal aortic dissection, which was confirmed by transesophageal echocardiography. Patients with proximal aortic dissection rarely have headache or neck pain, reflecting the low incidence of carotid artery involvement in this disease. However, differentiation between an isolated cervical artery dissection and a proximal aortic dissection extending to the carotid arteries is pivotal, since treatment options are vastly different.     

Acute aortic dissection mimicking an acute coronary syndrome through occlusion of the right coronary artery

Occlusion of the right coronary artery (RCA) is an uncommon complication of type A aortic dissection. Aortic dissection and acute coronary syndrome (ACS) share a similar pathogenesis in atherosclerosis and hypertension. Consequently a patient with ischaemic risk factors presenting with chest pain and dynamic ECG change may well be incorrectly treated for ACS if careful attention is not paid to the presenting symptoms and signs. This case report describes a 59-year-old man who presented with chest pain, confusion and an ischaemic ECG and was initially treated for ACS. He subsequently deteriorated clinically and imaging confirmed type A aortic dissection complicated by RCA occlusion. Following emergent surgery with aortic root replacement and coronary artery bypass grafting he later made a good recovery.     

Seeing the invisible: painless aortic dissection in the emergency setting

Acute dissection of the aorta can be one of the most dramatic cardiovascular emergencies. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterised as ripping or tearing in nature. However, a timely diagnosis can be elusive in the event of an atypical presentation. In this report, the authors present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department.     

北京市急诊胸痛的病因学调查分析

目的探讨北京市急诊科胸痛患者的病因学构成,为确立进一步的治疗方案提供依据,降低治疗费用。方法 本研究属多中心前瞻性描述性研究,参研单位包括17所医院。使用统一表格记录入选患者的一般资料,包括既往病史,发病时间,到达医院急诊时间,胸痛特点,心电图描述及诊断,初步诊断,急诊的诊治情况,辅助检查,确定诊断和去向,就诊30d后的临床转归情况。所有数据经SAS8．2统计软件进行统计学处理。结果2009年7—8月,在17个医疗中心连续有效人选至急诊室就诊的胸痛患者,计划纳入6000例,最终5666例患者确认获得有效记录而入选,平均年龄（58．1±18．4）岁,男性2663例,占47％;女性3003例,占53％。胸痛患者占急诊总量的4．7％（5666／130553）。病因学分析结果：冠心病1509例（27．4％）,急性心力衰竭149例（2．6％）,心包炎4例（0．1％）,肺栓塞11例（0．2％）,主动脉夹层8例（0．1％）,急性脑血管病431例（7．6％）,非心源性胸痛2538例（44．9％）。30d随访结果：院外死亡37例（O．7％）,再次入院275例（4．9％）。结论重视并认真对待胸痛患者,特别是无胸痛患者和以伴随症状就诊的患者,正确地做出诊断,及时进行规范诊疗,降低患者的病死率。     

Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome

OBJECTIVE: To evaluate the frequency, presentation and outcome of non-traumatic aortic dissection/rupture as a cause of cardiac arrest. DESIGN: Retrospective analysis of a cardiac arrest registry in a tertiary care hospital emergency department. RESULTS: Over 11.5 years, aortic dissection/rupture was identified as the immediate cause of cardiac arrest in 46 (2,3%) out of 1990 patients with sudden cardiac arrest, primarily affecting the abdominal aorta in 25 and the thoracic aorta in 21 cases. The characteristics of the 46 patients were as follows: male gender (74%), median age 71 years (IQR 59-76), high co-morbidity (89%), previously known aortic aneurysm (33%), pulseless electric activity (70%) as initial cardiac rhythm. When performed, bedside abdominal sonography or echocardiography was almost always diagnostic. Patients with abdominal aortic dissection/rupture had abdominal (52%) and/or flank pain (32%). Patients with thoracic aortic dissection/rupture complained of chest pain (48%) or dyspnoea (19%). Return of spontaneous circulation occurred in 12 (26%) of 46 patients, emergency surgery was performed in eight of these patients, 2 (4%) survived to discharge in good neurological condition. CONCLUSIONS: Cardiac arrest caused by aortic dissection/rupture is rare, and mortality remains very high, even when circulation can be restored initially. Common features such as previously known aortic aneurysm, old age, male gender and pulseless electrical activity as initial cardiac rhythm should increase suspicion of the condition.     

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

Background

Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis.

Objectives

To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection.

Case Report

An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation.

Conclusion

Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.     

Taming the zebra: Unravelling the barriers to diagnosing aortic dissection

Aortic dissection is a lethal cardiovascular emergency that continues to pose a diagnostic dilemma to the emergency physician. The condition is rare, can present atypically and is associated with a cumulative mortality for every hour that passes. While it is a recognised differential of acute chest pain, its prevalence in comparison to other causes often leads to the diagnosis being overlooked. The ED is a busy environment with high patient turnover and varying degrees of complexity and acuity. This increases susceptibility to cognitive bias and error‐producing conditions that can lead to delayed or missed diagnosis. In reported cases where aortic dissection has been missed, clinician awareness of the disease was not the primary issue but failure to respond to clinical cues suggestive of aortic dissection was. To improve patient outcomes for this condition, it is important for clinicians to be aware of pertinent cognitive bias and error‐producing conditions.