title: Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room.
abstract: BACKGROUND
  Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.
  
  
  METHODS
  We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.
  
  
  RESULTS
  An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).
  
  
  CONCLUSIONS
  WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Kazuhito
authors.initials: K
authors.lastname: Hirata
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Minoru
authors.initials: M
authors.lastname: Wake
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Takanori
authors.initials: T
authors.lastname: Takahashi
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Nakazato
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Nobuhito
authors.initials: N
authors.lastname: Yagi
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Tadayoshi
authors.initials: T
authors.lastname: Miyagi
authors.affiliation: Division of Cardiology, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Junichi
authors.initials: J
authors.lastname: Shimotakahara
authors.affiliation: Division of Cardiovascular Surgery, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Hidemitsu
authors.initials: H
authors.lastname: Mototake
authors.affiliation: Division of Cardiovascular Surgery, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Toshiho
authors.initials: T
authors.lastname: Tengan
authors.affiliation: Division of Emergency Department, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Tsuyoshi R
authors.initials: TR
authors.lastname: Takara
authors.affiliation: Division of Emergency Department, Okinawa Chubu Hospital, 281 Miyasato, Uruma, Okinawa, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Yamaguchi
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; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000503:physiopathology; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000503:physiopathology; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010146:Pain / Q000175:diagnosis / Q000503:physiopathology; D011379:Prognosis; D012189:Retrospective Studies; D013997:Time Factors