Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
LETTER TO EDITOR  
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 234-235
Inadequate management of patients with acute aortic symptoms before transfer from emergency departments


1 Department of Emergency Medicine; The R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
2 Department of Emergency Medicine, University of Maryland, Baltimore, MD, USA
3 The Research Associate Program in Emergency Medicine and Critical Care,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
4 Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
5 Campbell University School of Osteopathic Medicine, Buies Creek, NC, USA
6 Department of University of Maryland School of Medicine, Baltimore, MD, USA
7 Department of Emergency Medicine; Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA

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Date of Submission19-Jan-2020
Date of Acceptance03-Feb-2020
Date of Web Publication18-Sep-2020
 

How to cite this article:
Tran QK, Walker AM, Berman E, Vesselinov R, Rose M, Tiffany L, Bzhilyanskaya V, Naimi S, Alam Z, Abdalla N, Tanveer S, Yi JS, Lurie T, Hirshon JM. Inadequate management of patients with acute aortic symptoms before transfer from emergency departments. J Emerg Trauma Shock 2020;13:234-5

How to cite this URL:
Tran QK, Walker AM, Berman E, Vesselinov R, Rose M, Tiffany L, Bzhilyanskaya V, Naimi S, Alam Z, Abdalla N, Tanveer S, Yi JS, Lurie T, Hirshon JM. Inadequate management of patients with acute aortic symptoms before transfer from emergency departments. J Emerg Trauma Shock [serial online] 2020 [cited 2020 Dec 2];13:234-5. Available from: https://www.onlinejets.org/text.asp?2020/13/3/234/295371




Acute aortic symptoms (AAS) encompass a group of similar emergency clinical conditions: aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and aortic rupture.[1] Aortic dissection is the most common subgroup[2] but it is still a relatively uncommon disease, and emergency clinicians may only encounter one case every 3–4 years.[3] The American Heart Association (AHA) published a set of guidelines to provide a framework for the management of AAS.[2] This guideline recommends: (1) maintaining patients' systolic blood pressure (SBP) ≤120 mm Hg, (2) maintaining the patient's heart rate (HR) ≤60 bpm, and (3) adequate pain control.[2] However, how effectively patients with AAS are treated in the emergency department (ED) is relatively unknown.

We retrospectively analyzed the records of 168 patients who presented to any ED with AAS and SBP >120 mm Hg and HR >60 bpm, who were then admitted to our academic tertiary center for further management. Seventy-two (43%) patients had Type A dissections, 48% had Type B dissections, and 9% had other aortic emergencies (e.g., intramural hematoma or aortic aneurysm). Thirty-two patients (19%) achieved SBP ≤120 mm Hg, whereas 15 (9%) achieved goal HR ≤60 bpm when they left the ED. Multivariable logistic regressions, after adjusting for clinically and relevant independent variables showed that patients who received a higher total number of intravenous-push antihypertensive therapy (AHT) (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.0, 5.3, P < 0.01) and only AHT infusion (OR 5.4, 95% CI 1.8, 15, P < 0.001) had higher likelihood of achieving SBP ≤120 mm Hg when leaving the ED. There were no factors significantly associated with the likelihood of achieving HR goal ≤60 bpm. Patients' mortality and hospital length of stay were similar between groups achieving goals of SBP or HR, compared to those who did not.

The AHA recommends that SBP and HR in patients with AAS should be reduced quickly.[2] Therefore, a beta-blocker, especially labetalol with its α-adrenergic and β-adrenergic blocking characteristics, is recommended as the first-line agent for patients with AAS.[2] Furthermore, patients who have AAS are associated with hyperactivity of both central and peripheral sympathetic nervous systems and hence that they may require higher doses of AHT medications. This may partially explain our findings that a higher number of AHT interventions were associated with patients' higher likelihood of achieving the goal of SBP ≤120 mm Hg.

Previous studies suggested that persistent hypertension or higher HR than 60 bpm in patients with Type B dissection were associated with higher percentages of in-hospital mortality[4] or recurring aortic complications after discharge.[5] As a result, emergency physicians should consider treating patients who do not meet AHA guidelines for SBP and HR while patients are still in the ED.

Acknowledgment

The manuscript was copyedited by Linda J. Kesselring, MS, ELS. We also thank Alexander Henry, Sohail Hussain, Carina Newton, and Benchaa Boualam for their contributions to this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nienaber CA, Powell JT. Management of acute aortic syndromes. Eur Heart J 2012;33:26-35b.  Back to cited text no. 1
    
2.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr., et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: Executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv 2010;76:E43-86.  Back to cited text no. 2
    
3.
Alter SM, Eskin B, Allegra JR. Diagnosis of Aortic Dissection in Emergency Department Patients is Rare. West J Emerg Med 2015;16:629-31.  Back to cited text no. 3
    
4.
Trimarchi S, Eagle KA, Nienaber CA, Pyeritz RE, Jonker FH, Suzuki T, et al. Importance of refractory pain and hypertension in acute type B aortic dissection: Insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2010;122:1283-9.  Back to cited text no. 4
    
5.
Kodama K, Nishigami K, Sakamoto T, Sawamura T, Hirayama T, Misumi H, et al. Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection. Circulation 2008;118:S167-70.  Back to cited text no. 5
    

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Correspondence Address:
Quincy K Tran
Department of Emergency Medicine; The R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_4_20

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