Pleuritic chest pain and fever: An unusual presentation of aortic dissection

@#It remains a challenge to diagnose aortic dissection in primary care, as classic clinical features are not always present. This case describes an atypical presentation of aortic dissection, in which the patient walked in with pleuritic central chest pain associated with a fever and elevated C-reactive protein. Classic features of tearing pain, pulse differentials, and a widened mediastinum on chest X-ray were absent. This unusual presentation highlights the need for a heightened level of clinical suspicion for aortic dissection in the absence of classic features. The case is discussed with reference to the literature on the sensitivity and specificity of the classic signs and symptoms of aortic dissection. A combination of the aortic dissection detection risk score (ADD-RS) and D-dimer test is helpful in ruling out this frequently lethal condition.

Effect of D-dimer combined with risk score in screening of acute aortic dissection / 中国中西医结合急救杂志

Objective To discuss the diagnostic value of a diagnostic strategy combining D-dimer and aortic dissection detection risk score (ADDRS) for patients with acute aortic dissection (AAD). Methods The clinical data of 750 patients with suspected AAD in emergency department of Zhongda Hospital Affiliated to Southeast University from January 2016 to January 2018 were retrospectively analyzed, including medical history, gender, age, chief complaint, physical examination, diagnostic imaging data and D-dimer levels on admission. ADDRS = 0 was defined as low risk group, ADDRS = 1 as medium risk group, ADDRS≤1 as non-high risk group,whereas ADDRS > 1 as high risk group. The clinical characteristics of AAD and non-AAD patients, ADDRS, D-dimer, and the diagnostic ability of D-dimer (the cutoff value of 500 μg/L) for AAD in different risk groups were observed. Results AAD was diagnosed in 79 of 750 (10.53%) patients. Of the 256 (34.13%) patients in low risk group, 5 patients were diagnosed with AAD. The medium risk group had 337 (44.93%) patients, including 44 cases with AAD. The high risk group had 157 (20.93%) patients, including 30 cases with AAD. In AAD patients, the proportion of male and hypertension, the incidence of ADDRS risk markers (including abrupt onset of pain, severe pain intensity, ripping or tearing pain, pulse deficit or systolic blood pressure differential of upper limb, focal neurological deficit, recent aortic manipulation, known thoracic aortic aneurysm) and the D-dimer levels in AAD group were significantly higher than those of non-AAD patients [male: 82.28% (65/79) vs. 59.76% (401/671), hypertension: 81.01% (64/79) vs. 41.43% (278/671), abrupt onset of pain: 78.48% (62/79) vs. 39.94% (268/671), severe pain intensity: 78.48% (62/79) vs. 50.52% (339/671), ripping or tearing pain: 32.91% (26/79) vs. 0.75% (5/671), pulse deficit or systolic blood pressure differential of upper limb: 15.19% (12/79) vs. 0.15% (1/671), focal neurological deficit: 7.59% (6/79) vs. 1.64% (11/671), recent aortic manipulation: 6.33% (5/79) vs. 0.30% (2/671), known thoracic aortic aneurysm: 15.19% (12/79) vs. 0.30% (2/671), D-dimer (μg/L): 1 160 (588, 3 340) vs 135 (56, 478), all P < 0.05], the proportion of diabetics was significantly lower than that of non-AAD patients [7.59% (6/79) vs. 18.78% (126/671), P < 0.05]. The positive predictive values of D-dimer for AAD diagnosis in the low risk group and the non-high-risk groups (including low and medium risk groups) were lower than that in the high risk group (8.62%, 26.32% vs. 40.91%), the negative predictive values of D-dimer were higher in the low risk group and non-high-risk groups than that in the high risk group (100.00%, 99.05% vs. 96.70%), missed diagnosis rates were higher than that in high risk group (0, 0.95%, vs. 3.30%). Conclusion In the high risk group, D-dimer≥500 μg/L is helpful for diagnosis of AAD; and in low risk group or non-high-risk group, D-dimer < 500 μg/L can efficiently and accurately exclude AAD.

Value of aortic dissection detection risk score combined with D-dimer in patients with suspected acute aor-tic dissection / 实用医学杂志

Objective To assess the diagnostic value of combining aortic dissection detection risk score (ADDRS)with D-dimer in patients with suspected acute aortic dissection(AAD). Methods We retrospectively identified 525 patients with chest pain and with calculated ADDRS and available D-dimer on admission between January 2015 and December 2016. ADDRS ≤1 was defined as ′low probability′ and that >1 as ′high probability′. Results AAD were diagnosed in 106(20.2%)patients. In patients with ADDRS of 0,1 case of AAD was identi-fied and in those with ADDRS of 1,40 were identified while in 76 patients with ADDRS of 2 and 3,71 cases of AAD were identified. D-dimer with threshold of 0.5 mg/L had a negative predictive value of 100%and a specificity of 76.6% in patients with ADDRS of 0. In patients with ADDRS of 1,D-dimer had a negative predictive value of 98.6%. D-dimer showed a negative predictive value of 99.6% and a positive predictive value of 22.3% in patients with low probability. Conclusions High ADDRS benefits confirming AAD. Low ADDRS combined with negative D-dimer is safe and efficient for ruling out AAD ,while low ADDRS with positive D-dimer needs further aortic imaging.

Application value of aortic dissection detection risk score in diagnosis of acute aortic syndromes: analysis of 342 patients with acute chest pain enclosed / 中国中西医结合急救杂志

Objective To investigate the value of aortic dissection detection (ADD) risk score in the diagnosis of acute aortic syndromes (AAS). Methods Three hundred and forty-two patients with acute chest pain or back pain admitted to the Department of Emergency of the First Affiliated Hospital of Xiamen University from January 2013 to April 2016 were enrolled. At last, 71 patients were definitely diagnosed as AAS (AAS group), and 271 cases were diagnosed as non-AAS (non-AAS group). Furthermore, according to the ADD risk score, they were subdivided into two groups: low-risk (ADD score ≤ 1) and high risk (ADD score >1) subgroups. In the two groups, the ADD risk indexes and the proportions of patients with different risk scores were observed; the receiver operating characteristic curve (ROC curve) was drawn to evaluate the value of ADD risk score for diagnosing AAS. Results Compared with the non-AAS group, the proportions of patients in AAS group with indicators of high-risk pain characteristics, such as sudden pain and laceration-like pain were increased significantly [83.1% (59/71) vs. 31.0% (84/271), 29.6% (21/71) vs. 0 (0/271)];meanwhile, the proportions of patients with high-risk physical examination indicators, such as systolic blood pressure differences among the 4 extremities and the defect of local nerve function in AAS group were also significantly increased [23.9% (17/71) vs. 0 (0/271), 11.3% (8/71) vs. 0 (0/271), both P < 0.05]; the proportion of patients with high risk AAS score in AAS group was higher than that in the non-AAS group [66.2% (47/71) vs. 1.5% (4/271), P < 0.01]. The sensitivity of ADD score ≥ 1 for diagnosis of AAS and area under ROC curve (AUC) were all higher than those of ADD score ≥2 (sensitivity: 98.6% vs. 66.2%, AUC: 0.819 vs. 0.564), moreover, the specificity and the positive predictive value of ADD score ≥ 2 for diagnosis of AAS were higher than those of ADD score ≥ 1 (98.5% vs. 59.8%, 92.2% vs. 39.1%respectively). When the ADD risk score ≥ 1, its odds ratio (OR) = 104.0, 95% confidence interval (CI) was 0.761-0.877, P = 0.000; while ADD risk score ≥ 2, OR = 130.7, 95%CI was 0.516-0.612, P = 0.003. Conclusion It is shown that when ADD risk score (> 1) is used to diagnose AAS, it has relatively high sensitivity, when ADD score being high risk (> 1 score) is applied to diagnose AAS, its specificity is high, thus ADD risk score has important value in helping the early diagnosis of AAS.

Application value of aortic dissection detection risk score in diagnosis of acute aortic syndromes: analysis of 342 patients with acute chest pain enclosed / 中国中西医结合急救杂志

Objective To investigate the value of aortic dissection detection (ADD) risk score in the diagnosis of acute aortic syndromes (AAS). Methods Three hundred and forty-two patients with acute chest pain or back pain admitted to the Department of Emergency of the First Affiliated Hospital of Xiamen University from January 2013 to April 2016 were enrolled. At last, 71 patients were definitely diagnosed as AAS (AAS group), and 271 cases were diagnosed as non-AAS (non-AAS group). Furthermore, according to the ADD risk score, they were subdivided into two groups: low-risk (ADD score ≤ 1) and high risk (ADD score >1) subgroups. In the two groups, the ADD risk indexes and the proportions of patients with different risk scores were observed; the receiver operating characteristic curve (ROC curve) was drawn to evaluate the value of ADD risk score for diagnosing AAS. Results Compared with the non-AAS group, the proportions of patients in AAS group with indicators of high-risk pain characteristics, such as sudden pain and laceration-like pain were increased significantly [83.1% (59/71) vs. 31.0% (84/271), 29.6% (21/71) vs. 0 (0/271)];meanwhile, the proportions of patients with high-risk physical examination indicators, such as systolic blood pressure differences among the 4 extremities and the defect of local nerve function in AAS group were also significantly increased [23.9% (17/71) vs. 0 (0/271), 11.3% (8/71) vs. 0 (0/271), both P < 0.05]; the proportion of patients with high risk AAS score in AAS group was higher than that in the non-AAS group [66.2% (47/71) vs. 1.5% (4/271), P < 0.01]. The sensitivity of ADD score ≥ 1 for diagnosis of AAS and area under ROC curve (AUC) were all higher than those of ADD score ≥2 (sensitivity: 98.6% vs. 66.2%, AUC: 0.819 vs. 0.564), moreover, the specificity and the positive predictive value of ADD score ≥ 2 for diagnosis of AAS were higher than those of ADD score ≥ 1 (98.5% vs. 59.8%, 92.2% vs. 39.1%respectively). When the ADD risk score ≥ 1, its odds ratio (OR) = 104.0, 95% confidence interval (CI) was 0.761-0.877, P = 0.000; while ADD risk score ≥ 2, OR = 130.7, 95%CI was 0.516-0.612, P = 0.003. Conclusion It is shown that when ADD risk score (> 1) is used to diagnose AAS, it has relatively high sensitivity, when ADD score being high risk (> 1 score) is applied to diagnose AAS, its specificity is high, thus ADD risk score has important value in helping the early diagnosis of AAS.