Clinical examination for acute aortic dissection: A systematic review and meta-analysis

Abstract

Introduction

Acute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality.

Methods

We conducted a librarian assisted systematic review of Pubmed, Medline, Embase and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data extracted by two independent reviewers (agreement measured by Kappa). Studies were combined if low clinical and statistical heterogeonity (I²<30%). Study quality was assessed using the QUADAS-2 tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 were performed.

Results

We identified 792 records: 60 were selected for full text review, 9 studies with 2,400 participants were included (QUADAS-2 low risk of bias, Kappa 0.89(for full text review)). Prevalence of aortic dissection ranged from 21.9-76.1% (mean 39.1% SD 17.1%). The clinical findings increasing probability of aortic dissection were: 1) neurological deficit (n=3, specificity 95%, LR+ 4.4 95% CI 3.3-5.7, I² 0%), 2) hypotension (n=4, specificity 95%, LR+ 2.9 95% CI 1.8-4.6, I² 42%), and decreasing probability: absence of a widened mediastinum (n=4, sensitivity 76%-95%, LR- 0.14-0.60, I² 93%) and an American heart association (AHA) aortic dissection detection (ADD) risk score <1 (n=1 sensitivity 91%, LR- 0.22 95% CI 0.15–0.33).

Conclusions

Suspicion for acute aortic dissection should be raised with hypotension, pulse or neurological deficit. Conversely, a low AHA ADD score decreases suspicion. Clinical gestalt informed by high and low risk features together with an absence of an alternative diagnosis should drive investigation for acute aortic dissection.

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