Department of Emergency Medicine, 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):397-412. doi: 10.1111/acem.13360. Epub 2018 Jan 24.
Acute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality.
We conducted a librarian-assisted systematic review of PubMed, MEDLINE, Embase, and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data were extracted by two independent reviewers (agreement measured by kappa). Studies were combined if low clinical and statistical heterogeneity (I < 30%). Study quality was assessed using the QUADAS-2 tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 were performed.
We identified 792 records: 60 were selected for full text review, nine studies with 2,400 participants were included (QUADAS-2 low risk of bias, κ = 0.89 [for full-text review]). Prevalence of aortic dissection ranged from 21.9% to 76.1% (mean ± SD = 39.1% ± 17.1%). The clinical findings increasing probability of aortic dissection were 1) neurologic deficit (n = 3, specificity = 95%, positive likelihood ratio [LR+] = 4.4, 95% confidence interval [CI] = 3.3-5.7, I = 0%) and 2) hypotension (n = 4, specificity = 95%, LR+ = 2.9 95% CI = 1.8-4.6, I = 42%), and decreasing probability were the absence of a widened mediastinum (n = 4, sensitivity = 76%-95%, negative likelihood ratio [LR-] = 0.14-0.60, I = 93%) and an American Heart Association aortic dissection detection (AHA ADD) risk score < 1 (n = 1, sensitivity = 91%, LR- = 0.22, 95% CI = 0.15-0.33).
Suspicion for acute aortic dissection should be raised with hypotension, pulse, or neurologic deficit. Conversely, a low AHA ADD score decreases suspicion. Clinical gestalt informed by high- and low-risk features together with an absence of an alternative diagnosis should drive investigation for acute aortic dissection.
急性主动脉夹层是一种危及生命的疾病，其特征是主动脉壁撕裂。这种疾病难以诊断，如果漏诊，死亡率很高。
我们在 1968 年至 2016 年 7 月期间，通过图书馆员协助进行了系统的 PubMed、MEDLINE、Embase 和 Cochrane 数据库检索。由两名独立评审员（通过 Kappa 进行评估）审查标题和摘要，并提取数据。如果临床和统计学异质性较低（I ＜30%），则将研究合并。使用 QUADAS-2 工具评估研究质量。使用 Revman 5 和 SAS 9.3 进行双变量随机效应荟萃分析。
我们共确定了 792 条记录：60 条记录被选作全文审查，9 项研究纳入了 2400 名参与者（QUADAS-2 低偏倚风险，κ=0.89[用于全文审查]）。主动脉夹层的患病率范围为 21.9%至 76.1%（平均值±标准差=39.1%±17.1%）。增加主动脉夹层可能性的临床发现包括：1）神经功能缺损（n=3，特异性=95%，阳性似然比[LR+]=4.4，95%置信区间[CI]为 3.3-5.7，I=0%）和 2）低血压（n=4，特异性=95%，LR+=2.9，95%CI 为 1.8-4.6，I=42%），降低可能性的是纵隔不增宽（n=4，敏感性=76%-95%，阴性似然比[LR-]=0.14-0.60，I=93%）和美国心脏协会主动脉夹层检出（AHA ADD）风险评分＜1（n=1，敏感性=91%，LR-=0.22，95%CI 为 0.15-0.33）。
出现低血压、脉搏异常或神经功能缺损时，应怀疑为急性主动脉夹层。相反，AHA ADD 评分较低可降低怀疑。临床特征与高风险和低风险特征相结合，且无其他诊断，应推动对急性主动脉夹层的检查。
