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

Study Questions:

What factors are associated with delays in diagnosis and delays in therapy in acute type A aortic dissection?


The authors presented an analysis of data from the International Registry of Acute Aortic Dissection (IRAD), a collaborative observational registry that has collected information on unselected consecutive cases of acute aortic dissection at 24 centers in 11 countries, ongoing since January 1, 1996. Cases included up until January 2007 were evaluated for this study. Comprehensive clinical data pertaining to demographics, history, presentation, physical and imaging findings, management, and outcomes were collected in a 290-item data collection instrument from medical record review. For the purposes of this study, only type A aortic dissection cases were included in the analysis. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates to determine effect of individual variables.


There were 1,204 subjects included in this analysis, with a median time from arrival in the emergency room to diagnosis of 4.3 hours (quartile 1-3, 1.5-24 hours; n = 894 patients), and a median time from diagnosis to surgery of 4.3 hours (quartile 1-3, 2.4-24 hours; n = 751). Factors associated with delayed diagnosis included female sex; lack of abrupt onset pain or lack of chest pain, back pain, or any pain; lack of pulse deficit or hypotension; or transfer from a nontertiary care hospital (p < 0.05 for all). The largest relative DTRs were for fever (DTR = 5.11; p < 0.001) and transfer from a nontertiary care hospital (DTR = 3.34; p < 0.001). Surgical delay was associated with a history of prior cardiac surgery; absence of pain or abrupt onset pain; and transfer from nontertiary care hospital (p < 0.001 for all). Largest relative DTRs for delay in surgery were delay in diagnosis (DTR = 1.35; p < 0.001), nonwhite race (DTR = 2.25; p < 0.001), and history of coronary artery bypass surgery (DTR = 2.81; p < 0.001).


The authors concluded that improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.


This review of data from the IRAD, in which this reviewer participated, demonstrates an ideal application of observational registries: the evaluation of real-world clinical care delivery, and the statistical identification of factors associated with outcomes. In this case, the authors have identified factors associated with delayed time to diagnosis and delayed time from diagnosis to surgical therapy for patients suffering from acute aortic dissection. While such observations are only hypothesis generating, it is logical that patients presenting atypically (e.g., lacking pain, lacking typical pain, lacking pulse deficits) might suffer delays in diagnosis or treatment—most likely related to delays in consideration of aortic dissection. This study not only highlights the importance of targeted observational registries such as IRAD to study uncommon disorders such as aortic dissection, but it also highlights the need for more systematic clinical evaluation pathways that would include uncommon diagnoses into clinical consideration.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Emergency Medical Services, Chest Pain, Cardiology, Delayed Diagnosis, Hypotension, Back Pain, Coronary Artery Bypass, Cardiac Surgical Procedures, Octamer Transcription Factor-3, Critical Pathways

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