A missed diagnosis of acute aortic syndrome is associated with ischaemic ECG changes and an initial suspicion of myocardial infarction: a retrospective observational study.

backgroundAcute aortic syndrome (AAS) is a life-threatening condition reported as often misdiagnosed. Advancements in CT availability and diagnostic algorithms, including high-sensitivity troponin and D-dimer for acute coronary syndrome (ACS) and pulmonary embolism (PE), may reduce AAS misdiagnosis, but the impact remains unclear. This study evaluated the incidence, characteristics, and clinical features of missed AAS diagnoses in Swedish emergency departments (EDs) compared with those identified during initial ED visit.

methodsA retrospective observational study was conducted on 630,275 ED visits in Region Skåne, Sweden, from 2017 to 2018. Cases of AAS diagnosed within 30 days were identified via national registers. Clinical features, imaging, ECG findings, blood tests, outcomes, and time of diagnosis were reviewed. Missed diagnosis was defined as AAS not identified in the ED, with the patient being either discharged or admitted without imaging to detect AAS. Aortic dissection detection risk score (ADD-RS) combined with D-dimer levels were also retrospectively calculated.

resultsAmong 98 confirmed AAS cases, 82 were diagnosed during the initial ED visit, whereas 16 (16%; 95% CI: 9.6–25.1%) were initially missed, with 2 discharged from the ED. Patients with missed AAS diagnoses were more likely to present with ST elevation/depression than were those diagnosed during the initial ED visit (43% vs. 15%, p = 0.01). ACS was the initial working diagnosis in 7 of 16 of the missed cases. The median time to diagnosis was significantly longer in missed cases (19 h [2–192] vs. 2 h [0.5–11.6], p < 0.001). Missed cases had higher 30-day (25% vs. 16%) and 90-day mortality rates (38% vs. 18%), although these differences were not statistically significant. In 55 of the 59 AAS patients, the ADD-RS plus D-dimer algorithm recommended CT of the aorta (93% sensitivity).

conclusionMissed AAS remains a diagnostic challenge, with a miss rate of approximately one in six in Swedish EDs. Patients with missed AAS are more likely to present with ST changes and an initial suspicion of ACS. Given the overlap of symptoms, such as chest pain, with other critical conditions like ACS and PE, future ED diagnostic tools should be developed to predict multiple critical diagnoses concurrently.