Correlates of Delayed Recognition and Treatment of Acute Type A Aortic Dissection: The International Registry of Acute Aortic Dissection (IRAD)

An acute aortic dissection is a surgical emergency with a high mortality if left untreated. Given the varied presentations, including similarity to the far more common acute coronary syndromes, diagnosis and appropriate treatment are often delayed. This report evaluates the reasons for delay in the diagnosis of 894 patients in the International Registry of Acute Aortic Dissection Registry. Patients with the most typical presenting signs and symptoms, including abrupt onset of severe chest pain, and those with pulse deficits or hypotension, were diagnosed more quickly. In contrast, patients transferred from referral hospitals had significantly longer times to diagnosis and ultimately to surgery, perhaps related to the physician’s experience with dissection at these hospitals. Delays from diagnosis to surgery also occurred in nonwhites, those with prior cardiac surgery, and those without ongoing shock or hypotension. Education directed at recognition of both typical and atypical presentations of aortic dissection, particularly to those centers with low exposure to aortic emergencies, may be of benefit. The fact that the median times from presentation to diagnosis and from diagnosis to surgery exceeded 4 hours suggests that there is substantial room for improvement. The development of systematic care pathways for diagnosis and management of aortic dissection, similar to those in place for acute myocardial infarction, may be of benefit. The focus of these pathways should include recognition of both typical and atypical presentations, with rapid diagnostic imaging in appropriate candidates and prompt transfer and surgery. See p 1911.