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

Schönbeck, Hannah ; Björkelund, Anders LU ; Møller, Emilie Schønbeck ; Ekelund, Ulf LU orcid ; Björk, Jonas LU orcid and Forberg, Jakob Lundager LU (2025) In BMC Emergency Medicine 25(1).
Abstract

Background: Acute 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. Methods: A 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... (More)

Background: Acute 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. Methods: A 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. Results: Among 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). Conclusion: Missed 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.

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author
; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Acute aortic dissection, Acute aortic syndrome, Diagnostic delay, Missed diagnosis
in
BMC Emergency Medicine
volume
25
issue
1
article number
247
publisher
BioMed Central (BMC)
external identifiers
  • scopus:105023453184
  • pmid:41315990
ISSN
1471-227X
DOI
10.1186/s12873-025-01404-8
language
English
LU publication?
yes
id
66798c1f-f4bc-4110-8e41-c218a6ed543d
date added to LUP
2026-01-14 12:18:34
date last changed
2026-01-16 10:58:30
@article{66798c1f-f4bc-4110-8e41-c218a6ed543d,
  abstract     = {{<p>Background: Acute 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. Methods: A 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. Results: Among 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 &lt; 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). Conclusion: Missed 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.</p>}},
  author       = {{Schönbeck, Hannah and Björkelund, Anders and Møller, Emilie Schønbeck and Ekelund, Ulf and Björk, Jonas and Forberg, Jakob Lundager}},
  issn         = {{1471-227X}},
  keywords     = {{Acute aortic dissection; Acute aortic syndrome; Diagnostic delay; Missed diagnosis}},
  language     = {{eng}},
  number       = {{1}},
  publisher    = {{BioMed Central (BMC)}},
  series       = {{BMC Emergency Medicine}},
  title        = {{A missed diagnosis of acute aortic syndrome is associated with ischaemic ECG changes and an initial suspicion of myocardial infarction : a retrospective observational study}},
  url          = {{http://dx.doi.org/10.1186/s12873-025-01404-8}},
  doi          = {{10.1186/s12873-025-01404-8}},
  volume       = {{25}},
  year         = {{2025}},
}