Aortic dissection: clinical findings may help diagnose aortic dissection.

Clinical bottom line (level 4)

  1. A negative chest x-ray makes aortic dissection less likely, but could not rule it out.
  2. Proximal aortic dissection was more likely if there was aortic regurgitation, hypotension on initial examination or pulse deficits, and less likely if there was hypertension on initial examination.
  3. Distal aortic dissection was more likely if there was hypertension on initial examination.
Eagle et al: American Journal of Cardiology 1986; 57: 322-326
Expires December 2004

The study

Setting: university hospital, USA

176 patients (aged mean 58 years, 70% male) 51 with clinical picture suggesting aortic dissection, but with negative aortograms, and 125 patients with aortic dissection

Excluded if
  • history of trauma within 48 hours of study
  • > 36 hours after admission
  • elective admission
  • diagnosis of dissection 'not a true consideration'



    • Independent ?blinded reference standard, applied in some patients from a consecutive inappropriate spectrum.
    Reference standard:
    • angiogram, surgery or autopsy (during 1963-83)
    Diagnostic test: clinical findings, CXR, ECG

    The evidence

    pre-test probability of aortic dissection: 71%, (95% CI: 64% to 78%)
    pre-test probability of proximal dissection: 31%, (95% CI: % to %)
    pre-test probability of distal dissection: 40%, (95% CI: % to %)

    differential diagnosis number of patients prevalence
    (95% CI)
    myocardial infarction 9 5.1%
    (1.9% to 8.4%)
    aortic regurgitation 5 2.8%
    (0.4% to 5.3%)
    thoracic non-dissecting aneurysm 4 2.3%
    (0.1% to 4.5%)
    musculoskeletal pain 4 2.3%
    (0.1% to 4.5%)
    mediastinal cyst or tumour 4 2.3%
    (0.1% to 4.5%)
    pericarditis 3 1.7%
    (0.0% to 3.6%)
    gallstones 2 1.1%
    (0.0% to 2.7%)
    pleuritis 1 0.6%
    (0.0% to 1.7%)
    PE 1 0.6%
    (0.0% to 1.7%)
    unknown 14 8.0%
    (4.0% to 12%)


    diagnostic test aortic dissection present dissection absent LR+
    (95% CI)    		 LR-
    (95% CI)
    prior hypertension 86 25 1.4
    (1.0 to 1.9)     		0.61
    (0.42 to 0.89)
    symptoms < 24 hours 100 27 1.5
    (1.2 to 2.0)     		0.43
    (0.27 to 0.67)
    pain migration 86 26 1.4
    (1.0 to 1.8)     		0.64
    (0.43 to 0.93)
    LVH on admission ECG 52 10 2.1
    (1.2 to 3.8)     		0.73
    (0.59 to 0.89)
    total 125 51


    diagnostic test aortic dissection present dissection absent LR+
    (95% CI)    		 LR-
    (95% CI)
    possibly abnormal aorta on CXR 111 40 1.3
    (1.1 to 1.6)     		0.16
    (0.061 to 0.41)
    total 116 55


    diagnostic test proximal aortic dissection present dissection absent LR+
    (95% CI)    		 LR-
    (95% CI)
    hypertension on initial examination (> = 150/90) 6 68 0.19
    (0.089 to 0.42)     		2.0
    (1.6 to 2.5)
    hypotension on initial examination (systolic < 100) 12 5 5.3
    (2.0 to 14)     		0.82
    (0.71 to 0.94)
    pulse deficits 26 16 3.6
    (2.1 to 6.1)     		0.61
    (0.47 to 0.79)
    aortic regurgitation 36 14 5.7
    (3.3 to 9.6)     		0.39
    (0.27 to 0.57)
    total 55 121


    diagnostic test distal aortic dissection present dissection absent LR+
    (95% CI)    		 LR-
    (95% CI)
    hypertension on initial examination 46 28 2.5
    (1.7 to 3.6)     		0.47
    (0.33 to 0.66)
    total 70 106

    • On subsequent partial follow-up: 4 false negative aortograms (i.e. 93% sensitivity)

    Comments

    1. The retrospective nature of study and the fact that only patients having aortograms were studied makes signs and symptoms more favourable than in reality.

    Citation

    1. Eagle KA, Quertermous T, Kritzer GA, et al: Spectrum of conditions initially suggestive of acute aortic dissection but with negative aortograms. American Journal of Cardiology 1986; 57: 322-326
    2. Slater EE, and DeSanctis RW: Clinical recognition of dissecting aortic aneurysm. American Journal of Medicine 1976; 60: 625-633

       

    Contributor: Chris Ball and Clare Wotton, December 2000
    Reviewer:

    Clinical Question.
    Patient suspected aortic dissection
    Intervention or Exposure clinical findings
    Outcome diagnosis