title: Factors leading to failure to diagnose acute aortic dissection in the emergency room.
abstract: BACKGROUND
  Acute aortic dissection (AAD) is often missed on initial assessment.
  
  
  OBJECTIVE
  The aim of our study was to identify features associated with misdiagnosis of AAD.
  
  
  RESULTS
  We examined a total of 109 emergency room (ER) patients who were ultimately diagnosed with AAD. Misdiagnosis of AAD was defined as failure to diagnose AAD at the end of the initial assessment in the ER, and occurred in 17 patients (16%). The alternate diagnosis consisted of acute coronary syndrome (n=10), other cardiovascular disease (n=3), abdominal disease (n=3), and cerebral infarction (n=1). In the misdiagnosed patients, walk-in mode of admission to the ER (29% vs. 10%, p=0.042) and anterior chest pain (71% vs. 41%, p=0.025) were more frequent, and widened mediastinum (25% vs. 55%, p=0.023) was less frequent than in diagnosed patients. The number of imaging studies performed per patient was also fewer in misdiagnosed patients than in diagnosed patients (0.82 ± 0.81 vs. 1.53 ± 0.52, p<0.001). However, there was no significant difference in in-hospital mortality (18% vs. 15%, p=0.520). Multivariate analysis showed that the strongest predictor of misdiagnosis was walk-in mode of admission (odds ratio 4.777; 95% confidence interval 1.267-18.007; p=0.021).
  
  
  CONCLUSIONS
  Both diversity of symptoms and variability of the severity of symptoms, especially walk-in mode of admission lead ER physicians to miss AAD in about 1 in 6 cases of AAD. It is therefore important to keep AAD as a differential diagnosis in mind, even when patients present with mild enough symptoms that allow them to walk into the ER.
authors: Division of Cardiology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan. kurabayashi.card@yokohama.jrc.or.jp
authors: Manabu
authors: M
authors: Kurabayashi
authors: Naoyuki
authors: N
authors: Miwa
authors: Daisuke
authors: D
authors: Ueshima
authors: Koji
authors: K
authors: Sugiyama
authors: Kojiro
authors: K
authors: Yoshimura
authors: Tsukasa
authors: T
authors: Shimura
authors: Hideshi
authors: H
authors: Aoyagi
authors: Koji
authors: K
authors: Azegami
authors: Kaoru
authors: K
authors: Okishige
authors: Mitsuaki
authors: M
authors: Isobe
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis* / Q000503:physiopathology; D001014:Aortic Aneurysm / Q000175:diagnosis* / Q000503:physiopathology; D016001:Confidence Intervals; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D003952:Diagnostic Imaging; D003955:Diagnostic Tests, Routine; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012720:Severity of Illness Index