AHRQ Commentary Examines Challenges of Diagnosing and Managing AAD

Acute aortic dissection (AAD), although rare, is challenging to diagnose, as patients may not present with the classic sudden onset of tearing, sharp chest pain, or pulse deficits but instead with painless manifestations involving other body systems, states the author of a commentary from the April 2015 edition of the Agency for Healthcare Research and Quality's (AHRQ) online case study review, WebM&M. In the spotlight case, a 78-year-old woman with a past medical history of hypertension presented to the emergency department (ED) after an acute period of confusion followed by possible gastrointestinal bleeding. She had no abdominal pain, chest pain, shortness of breath, or focal weakness in her arms or legs, and although her physical examination was notable for tachycardia, her mental status examination and chest radiograph were normal. After being diagnosed with a transient ischemic attack and admitted to a telemetry unit for monitoring, the patient was found in cardiac arrest two days later and subsequently died from what an autopsy found to be AAD. According to the commentary's author, the diagnosis of AAD in the ED is missed 16% to 38% of the time—a problem research has linked to factors such as perceived mildness of disease at presentation, clinical symptoms and laboratory findings that suggest another disease, and the absence of "typical" radiographic findings.