An index of open-access aortic dissection content relevant to primary care
Risk Factors for In-hospital Mortality in Aortic Dissection：a 18-year Retrospective Study
CHEN Jing1，HE Jun2*
1.Special Needs Ward 2，General Hospital of Ningxia Medical University，Yinchuan 750004，China
2.Cardiovascualr Department，Heart Center，General Hospital of Ningxia Medical University，Yinchuan 750004，China *Corresponding author：HE Jun，Chief physician，Associate professor；E-mail：Junhe@nyfy.com.cn
Abstract: Background Aortic dissection（AD） progresses rapidly once it occurs，and it has a relatively high mortality.According to overseas epidemiological statistics，AD has an incidence of 5/100 000 0 to 30/100 000 0.But timely diagnosis and reasonable treatment can reduce the mortality.Objective To perform an analysis of in-hospital mortality and associated risk factors of AD and the changes in related diagnostic and therapeutic strategies based on 18-year data from General Hospital of Ningxia Medical University.Methods 752 AD inpatients from General Hospital of Ningxia Medical University were enrolled from January 2000 to December 2017.Demographic（gender，age，smoking history，alcohol consumption history，length of stay） and clinical data（symptoms，vital signs，comorbidities，complications，imaging and laboratory data） were collected.Changes in admission departments during these years were analyzed.Treatment option（medication or medication with surgery） and outcome（death or survival） of them were compared between type A patients（n=237） and type B patients（n=515） stratified by Stanford classification of AD.Treatment option，in-hospital mortality，and nosocomial infection incidence were compared between those treated in 2000—2008（group 1，n=196） and those treated in 2009—2017（group 2，n=556）.In-hospital outcomes（104 deaths and 648 survivals） were analyzed.Factors associated with in-hospital mortality of AD were identified by multivariate Logistic regression.Results Of the participants，65（8.64%） and 687（91.36%） hospitalized in internal medicine department，and surgery department，respectively.The number of patients and those hospitalized in surgery department increased with years，showing similar growth trends.But the annual number of those hospitalized in internal medicine department maintained less than 10.253（33.64%）.253（33.64%） and 499（66.36%） received medical treatment，and surgical treatment，respectively.Treatment options differed significantly across type A and type B patients（P<0.001）.Type A patients showed a higher in-hospital mortality（P<0.001）.The proportion of medical treatment，in-hospital mortality and in-hospital mortality of type A patients in group 1 were higher than those in group 2（P<0.05）.Multivariate Logistic regression analysis showed that type A dissection，increased heart rate，elevated white blood cell count，and nosocomial infection were associated with increased risk of in-hospital mortality of AD（P<0.05）.Conclusion The in-hospital mortality of AD was reduced significantly during this period in the hospital.Surgical treatment may be an effective treatment for AD.Type A dissection，increased admission heart rate，elevated white blood cell count，and nosocomial infection were independent risk factors of in-hospital mortality of AD.
Rapid emergency diagnostic analysis of atypical acute aortic dissection
JIANG Youjin*，LI Juan，ZHANG Zhengfang，ZHU Bing
Department of Emergency，Maanshan People's Hospital，Maanshan 243000，China *Corresponding author：JIANG Youjin，Associate chief physician；E-mail：jiangyoujinjzk@126.com
Abstract: Background Acute aortic dissection （AAD） is a rare but fatal aortic disease if left untreated.Patients with continuous severe chest and back pain，high risk factors and obvious physical findings are hardly misdiagnosed or have a missed diagnosis，but those with atypical symptoms are difficult to be diagnosed timely.Therefore，it is urgent to formulate diagnostic framework for atypical AAD.Objective To summarize a rapid emergency diagnostic and therapeutic procedure for atypical AAD，and to analyze the improvement in waiting time for a confirmed diagnosis and retention time in emergency department.Methods We collected the clinical data of 91 AAD patients who had been diagnosed and misdiagnosed by Department of Emergency，Maanshan People's Hospital from January 2012 to December 2018，and divided them into typical AAD group（n=51） and atypical AAD group（n=40）according to clinical manifestations and final diagnostic results，then further divided atypical AAD patients into control subgroup （n=24，admitted from January 2012 to December 2015），and observation subgroup （n=16，admitted from January 2016 to December 2018） according to the admission time.We used two diagnostic procedures although efforts have been made to explore and improve the procedure since the first atypical patient had been found in our hospital in 2012.Before 2016，due to insufficient understanding of AAD，we diagnosed suspected AAD patients without performing examinations such as routine blood test，measurement of serum C-reactive protein，electrolytes，and amylase，ECG，liver and kidney functions，urine amylase，PT，APTT，TT and FIB，myocardial enzyme and CTnI，and D-Dimer，as well as CT scan when necessary.Since 2016，we used a different diagnostic procedure revised based on gradually improved understanding of atypical AAD gained by years of summary and learning of aortic disease-related knowledge and literature review，and the suspected AAD patients are diagnosed based on data including the aforementioned examinations，for those highly suspected，if the aforementioned examinations are not sufficient to make a confirmed diagnosis，aortic angiography was performed additionally.We compared the demographic data，missed diagnosis，misdiagnosis，time of confirmed diagnosis，retention time in emergency department，and outcome across the typical patients，control and observation atypical patients.Results Sex ratio （χ2=0.024，P=0.989） and mean age （F=2.594，P=0.080） showed no significant differences across typical AAD group，control and observation atypical AAD subgroups.One observation atypical patient and 1 control atypical patient as well as 5 typical patients were misdiagnosed.The mean time for making a diagnosis for those with correct diagnosis in typical AAD group，control atypical AAD subgroup and observation atypical AAD subgroup was （27.6±16.8） min，（38.8±21.6） min，and （19.1±7.4） min，respectively，showing a significant difference（F=6.180，P=0.003）.The mean retention time in emergency department for typical AAD group，control and observation atypical AAD subgroups was 0，3.4（8.9） hours，and 1.5（1.0） hours，respectively.The control atypical AAD subgroup had a longer mean retention time in emergency department than observation atypical AAD subgroup （Z=-3.875，P<0.001）.77 patients were transferred to higher level hospitals，the other 12 patients were treated in our hospital，11 of whom received pharmacological treatment，and the other 1 received stent implantation.Two typical AAD patients died within 1 hour after diagnosis.Conclusion To improve the diagnostic accuracy of atypical AAD to save time for further treatment，measurement of D-Dimer and CT scan or together with CTA when necessary should be performed for suspected atypical AAD patients during the initial examination as far as possible.In addition，learning of clinical symptoms and imaging features of atypical AAD should be strengthened in front-line clinicians and emergency diagnostic and therapeutic procedure for atypical AAD should be standardized.
Advances in delayed surgery in patients with aortic dissection
XIAO Yaru，HUANG Sufang*，DENG Juan，HE Mei，LI Miqi，ZHOU Quan
Department of Emergency，Tongji Hospital，Tongji Medical College，Huazhong University of Science & Technology，Wuhan 430030，China *Corresponding author：HUANG Sufang，Chief superintendent nurse；E-mail：sfhuang2008@163.com
Abstract: Aortic dissection is a dangerous disease with rapid progression.Timely and effective surgical treatment is the key treatment method，but is often delayed to varying degrees.In this paper，the definition，current situation and causes of delayed surgery in patients with aortic dissection were summarized based on the reviewing of related articles，It's found that referral，history of cardiac surgery，painless，acute heart failure，severe complications and preoperative coronary angiography were the main influencing factors,aiming at increasing people's understanding of surgical delay in these patients，and providing theoretical support for formulating targeted intervention measures to shorten the delay time.
Advances in delayed diagnosis in patients with aortic dissection
XIAO Yaru，HUANG Sufang*，YAN Li，LI Miqi，ZHOU Quan
Department of Emergency，Tongji Hospital，Tongji Medical College，Huazhong University of Science & Technology，Wuhan 430030，China *Corresponding author：HUANG Sufang，Chief superintendent nurse；E-mail：sfhuang2008@163.com
Abstract: The initial symptoms of aortic dissection are diverse，and the rate of misdiagnosis and missed diagnosis is high.Moreover，timely diagnosis is crucial for prognosis of aortic dissection.The article summarizes the time of diagnosis of aortic dissection，and summarizes the factors affecting the delayed diagnosis of aortic dissection from demographic factors，past medical history，clinical features or signs，and related examinations，show that gender，geographical difference，referral，admission mode，previous history (history of cardiac surgery，history of aortic dissection)，clinical manifestations or signs (typical clinical manifestations or signs，atypical manifestations or signs (no pain，abdominal pain，pleural effusion，dyspnea，etc.)，relevant examination (positive cardiac troponin，abnormal ECG，no mediastinal widening in chest X-ray examination，diagnostic examination number of inspections) are the main influencing factor，in order to provide a theoretical basis for clinicians to quickly identify aortic dissection.At the same time，in the clinical nursing work，it is important to the initial triage of the aortic dissection and the observation of the condition during the observation period.
Time interval from onset to first hospital admission in patients with acute aortic dissection
XIAO Yaru，HUANG Sufang*，YAN Li，DENG Juan，HE Mei，LI Miqi，ZHOU Quan
Department of Emergency，Tongji Hospital，Tongji Medical College，Huazhong University of Science & Technology，Wuhan 430030，China *Corresponding author：HUANG Sufang，Chief superintendent nurse；E-mail：sfhuang2008@163.com
Abstract:
Background Acute aortic dissection（AAD） is characterized by acute onset and rapid progress.Some patients die before reaching hospital.But available studies concerning time interval from onset of AAD to hospital admission are rare.Objective This study aimed to explore the time interval from onset of AAD to first hospital admission and associated factors in AAD patients，providing theoretical support for shortening prehospital time to timely obtain hospital care in such patients.Methods A total of 173 patients with AAD from department of cardiac macrovascular surgery of a grade A tertiary hospital，Wuhan were enrolled during March to November，2018.A self-developed questionnaire named Prehospital Time in Acute Aortic Dissection Patients was used to survey the patients to collect demographics，AAD-related factors and factors possibly associated with prehospital time.Multiple linear regression analysis was used to determine the factors associated with prehospital time.Results The survey obtained a response rate of 86.50%（173/200）.The prehospital time in the 173 respondents was 12-20 350 minutes〔averaged 70.0（36.5，150.0）〕 minutes.The prehospital time varied significantly according to education level，monthly income，prevalence of independent living，time required to access to the nearest medical institution from home，history of past illness（i.e.gastric disease），smoking and drinking prevalence，onset symptoms （chest or back pain，profuse sweating，dyspnea），level of pain at onset，prevalence of persistent pain at onset，history of symptoms similar to onset symptoms，perceptions of AAD，onset time，what is being done at the onset time，bystander response，self-perceived severity of disease，means of admission（by dialing 120 to call an ambulance，going to the hospital by oneself or under the help of others，by calling for help，seeking hospital care due to other diseases），and prehospital interventions（try to rest or relax，bearing the suffering till symptom relief，medication） （P<0.05）.Multiple linear regression analysis showed that education level，time required to access to the nearest medical institution from home，prevalence of persistent pain at onset，bystander response，self-perceived severity of disease，going to the hospital by taxi，and seeking hospital care due to other diseases were associated with the prehospital time（P<0.05）.Conclusion Higher education level was associated with shorter time used to access to the nearest medical institution from home.Higher self-perceived severity of disease was associated with shorter prehospital time.Moreover，having persistent pain at the onset，positive response of the bystanders，and dialing 120 to call an ambulance were associated with shorter prehospital time.However，seeking hospital care due to other diseases was associated with longer prehospital time.In view of this，to shorten the prehospital time to timely obtain hospital care，public perceptions and vigilance consciousness of AAD need to be improved，active interventions should be taken after the onset，and dialing 120 to call an ambulance is recommended.
Association between Admission Serum Sodium and In-hospital Postoperative 30-day Mortality in Acute Aortic Dissection Patients
WANG Hongyan1，ZHAO Yongbo2，LIU Xiao2，SU Peng1，ZHANG Jinjin1，MA Shuo1，PAN Zhe1，SHI Juexin1，HOU Fangfang1，ZHANG Nana1，ZHENG Xiaohui1，LIU Nan1，ZHANG Ling1，MA Dong1*
1.School of Public Health，North China University of Science and Technology，Tangshan 063210，China
2.Department of Cardiac Surgery，the Fourth Hospital of Hebei Medical University，Shijiazhuang 051000，China
*Corresponding author：MA Dong，Assistant researcher，Master supervisor；E-mail：mamamadong@163.com
Abstract: Background Acute aortic dissection（AAD）is a macrovascular disease with acute onset，quick progression and high mortality. Studies indicate that the severity of hypersodium is associated with in-hospital death. However，the relationship between admission serum sodium and in-hospital death of patients with AAD remains little known. Objective To examine whether in-hospital postoperative mortality associates with admission serum sodium，and its associated risk factors in patients with AAD. Methods Four hundred and fifteen AAD inpatients from Department of Cardiac Surgery，the Fourth Hospital of Hebei Medical University were enrolled during January 2015 to December 2019. General clinical data，and baseline laboratory results were collected. The endpoint was in-hospital all-cause mortality. The Kaplan-Meier estimate was used to compute the in-hospital postoperative 30-day cumulative survival in quartile groups of admission serum sodium（Q1：≤136 mmol/L，Q2：137-138 mmol/L，Q3：139-140 mmol/L，Q4：≥141 mmol/L）. The Cox proportional-hazards model was used to examine the association of admission serum sodium with in-hospital postoperative mortality，and risk factors associated with in-hospital postoperative mortality. Results Q1-4 groups（n=114，103，102，96）had statistically significant differences in variables involving mean age，prevalence and mortality of Stanford-A AAD，in-hospital mortality，and mean levels of blood urea nitrogen，serum neutrophil count，monocyte count，and chloride（P<0.05）. In particular，Q4 group had much higher mean neutrophil count and in-hospital mortality than other groups（P<0.05）. The survival of in-hospital postoperative 30-day mortality differed significantly across the four quartile groups（χ2=10.994，P=0.012）. The in-hospital postoperative 30-day cumulative survival in Q1 group was statistically different compared with that of Q3 group and Q4 group（χ2=6.282，P=0.012；χ2=9.632，P=0.002）. Cox regression analysis demonstrated that the risk of death was 2.890〔95%CI（1.264，6.604），P=0.012〕 in Q3 group，and was 3.253〔95%CI（1.447，7.312），P=0.004〕 in Q4 group. After adjusting for age and gender，the risk of death in Q3 and Q4 groups was 2.825〔95%CI（1.228，6.502），P=0.015〕 and 3.241〔95%CI（1.441，7.290），P=0.006〕，respectively. After adjusting for all covariates，the risk of death in Q3 and Q4 groups was 3.086〔95%CI（1.242，7.671），P=0.015〕 and 3.370〔95%CI（1.384，8.204），P=0.007〕，respectively. The risk of death in Q2 group changed insignificantly before and after partial or fully adjusting for the covariates（P<0.05）. Multivariate Cox regression analysis revealed that Stanford-A AAD 〔HR=3.634，95%CI（1.638，8.086），P=0.002〕，plasma glucose 〔HR=1.077，95%CI（1.025，1.132），P=0.002〕，α-HBDH〔HR=1.001，95%CI（1.001，1.002），P<0.001〕 and serum sodium〔HR=1.068，95%CI（1.029，1.109），P=0.001〕 were associated with in-hospital postoperative 30-day mortality in patients with AAD. Conclusion The in-hospital postoperative 30-day mortality may be associated with the serum sodium at admission in AAD patients，and the risk of the former may increase with the elevation of the latter.
Bayes Discriminant Analysis for In-hospital Death of Aortic Dissection
ZHANG Weizong1，MA Xiang2*，YUAN Hong1*，SUN Jindong1，HU Haiqiang1，SHI Mingjuan1，YU Huamin1，HE Haiying1，YE Li1
1.Cardiovascular Department，First People's Hospital of Yuhang District，Hangzhou 311100，China
2.No.2 Department of Coronary Heart Disease，the First Teaching Hospital of Xinjiang Medical University，Urumqi 830000，China
*Corresponding authors：MA Xiang，Professor，Chief physician；E-mail：maxiangxj@yeah.net
YUAN Hong，Professor，Chief physician；E-mail：yuhangyhy@yeah.net
Abstract: Background Aortic dissection（AD） is an acute critical disease of the cardiovascular system characterized by acute onset and high mortality.There is lack of studies in which effective models for predicting the in-hospital outcome in patients with AD are reported.However，there is an urgent clinical need for an effective and reliable model for predicting in-hospital outcomes of AD as AD incidence has recent increases.Objective To develop Bayes formulas to predict in-hospital death of AD patients，providing a reference for the formulation of effective treatments of this disease.Methods According to the unified inclusion and exclusion criteria of this study，553 cases of AD were enrolled during January 2010 to December 2015，including 228 from First People's Hospital of Yuhang District，and 325 from the First Teaching Hospital of Xinjiang Medical University.Clinical data such as general personal characteristics，basic signs，and laboratory indices were collected.By the in-hospital outcome，participants were divided into the survival group （n=470） and death group（n=83）．Differential variables were identified based on the results of univariate analysis.A sample set was selected using a computer-based random number generator，and their data were included in the Bayes formulas derived from Bayes discriminant analysis.The remaining participants were defined as a test set，and their data were included in the Bayes formulas to verify the accuracy of the formulas.Results The participants had a mean age of （51.5±12.3） years，a ratio of male to female of 3.89∶1 and an in-hospital mortality rate of 15.0%（83/553）．The variables finally substituted in the Bayes formulas were onset time（a1），DeBakey types （a2），urea nitrogen （a3），random plasma glucose （a4），glycated serum protein（a5），indirect bilirubin （a6），international normalized ratio （a7），and fibrinogen （a8），and the derived formulas were Q1=-1.174×a1+6.813×a2+0.323×a3+0.213×a4+10.522×a5+0.171×a6+25.656×a7+1.014×a8-39.843 and Q2=-13.336×a1+27.131×a2
-1.928×a3-5.030×a4+35.574×a5-0.658×a6+287.333×a7 -3.509×a8-1 707.601.And the significance of the formulas could be explained as：after putting the aforementioned variables（a1-a8） of an AD patient into the formulas，if the value of Q1 is greater than that of Q2，then the patient is determined as a survivor，otherwise he is a deceased.The formulas were found with an accuracy rate of 98.85% and an error rate of 1.15%（P=0.003）after being tested with the data of the participants in the test set，and were identified with an accuracy rate of 98.73%，and an error rate of 1.27%（P<0.001）after being tested with the data of all the participants.Conclusion Our Bayes formulas can be used to predict the in-hospital outcome of AD patients from a statistical perspective.