Department of Emergency Medicine, the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario.
Department of Undergraduate Medicine, University of Ottawa, Ottawa, Ontario.
Acad Emerg Med. 2018 Apr;25(4):378-387. doi: 10.1111/acem.13356. Epub 2018 Jan 15.
Acute aortic dissection (AAD) is a rare condition with a high mortality that is often missed. The objective of our study was to assess the diagnostic accuracy of clinical and laboratory findings for AAD, in confirmed cases of AAD and in a low-risk control group.
This was a historical matched case-control study: participants were adults > 18 years old presenting to two tertiary care emergency departments (EDs) or one regional cardiac referral center. Cases were patients with new ED or in-hospital diagnosis of nontraumatic AAD confirmed by computed tomography or echocardiography. Controls were patients with a triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:4 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2.
Data were collected from 2002 to 2014 yielding 194 cases of AAD and 776 controls (mean ± SD age = 65 ± 14.1 years; 66.7% male). Absence of abrupt-onset pain (sensitivity = 95.9%, negative likelihood ratio = 0.07 [0.03-0.14]) can help rule out AAD. Presence of tearing/ripping pain (specificity = 99.7%, positive likelihood ratio [LR+] = 42.1 [9.9-177.5]), aortic aneurysm (specificity = 97.8%, LR+ = 6.35 [3.54-11.42]), hypotension (specificity = 98.7%, LR+ = 17.2 [8.8-33.6]), pulse deficit (specificity = 99.3, LR+ = 31.1 [11.2-86.6]), neurologic deficits (specificity = 96.9%, LR+ = 5.26 [2.9-9.3]), and a new murmur (specificity = 97.8%, LR+ = 9.4 [5.5-16.2]) can help rule in the diagnosis of AAD.
Patients with one or more high-risk feature should be considered high risk, whereas patients with no high-risk and multiple low-risk features are at low risk for AAD.
急性主动脉夹层（AAD）是一种死亡率很高的罕见疾病，常常被漏诊。我们的研究目的是评估临床和实验室检查在确诊的 AAD 病例和低危对照组中的诊断准确性。
这是一项回顾性匹配病例对照研究：参与者为年龄大于 18 岁，在两个三级急救部门（ED）或一个区域性心脏转诊中心就诊的成年人。病例为新发 ED 或医院内诊断为非创伤性 AAD 的患者，通过计算机断层扫描或超声心动图证实。对照组为分诊诊断为躯干疼痛（<14 天）且基本检查无明确诊断的患者。病例和对照组按性别和年龄以 1:4 的比例匹配。根据 80%的效能和 95%置信区间计算出需要 165 例病例和 660 例对照的样本量，以检测大于 2 的优势比。
2002 年至 2014 年收集的数据共纳入 194 例 AAD 病例和 776 例对照组（平均年龄±标准差为 65±14.1 岁；66.7%为男性）。无突发痛（敏感性为 95.9%，阴性似然比为 0.07[0.03-0.14]）有助于排除 AAD。存在撕裂样疼痛（特异性为 99.7%，阳性似然比为 42.1[9.9-177.5]）、主动脉瘤（特异性为 97.8%，阳性似然比为 6.35[3.54-11.42]）、低血压（特异性为 98.7%，阳性似然比为 17.2[8.8-33.6]）、脉搏缺失（特异性为 99.3，阳性似然比为 31.1[11.2-86.6]）、神经功能缺损（特异性为 96.9%，阳性似然比为 5.26[2.9-9.3]）和新出现的杂音（特异性为 97.8%，阳性似然比为 9.4[5.5-16.2]）有助于诊断 AAD。
有一个或多个高危特征的患者应被视为高危，而无高危特征且有多个低危特征的患者发生 AAD 的风险较低。
