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Acute Aortic Dissection Presenting With Primarily Abdominal Pain: A Rare Manifestation of a Deadly Disease
the hospital. In the unadjusted analysis, gender and racial differences were observed for rates of reperfusion therapy (for white men, white women, black men, and black women: 86.5%, 83.3%, 80.4% and 77.8%, respectively; p⬍0.001), use of aspirin (84.4%, 78.7%, 83.7% and 78.4%, respectively; p⬍0.001), use of beta-blockers (66.6%, 62.9%, 67.8% and 64.5%; p⬍0.001), and coronary angiography (69.1%, 55.9%, 64.0%, and 55.0%; p⬍0.001). After multivariable adjustment, racial and gender differences persisted for rates of reperfusion therapy (risk ratio for white women, black men, and black women: 0.97, 0.91 and 0.89, respectively, as compared with white men) and coronary angiography (relative risk, 0.91, 0.82 and 0.76) but were attenuated for the use of aspirin (risk ratio, 0.97, 0.98 and 0.94) and beta-blockers (risk ratio, 0.98, 1.00 and 0.96); all risks were unchanged over time. Adjusted in-hospital mortality was similar among white women (risk ratio, 1.05; 95%CI 1.03–1.07) and black men (risk ratio, 0.95; 95%CI 0.89 –1.00), as compared with white men, but was higher among black women (risk ratio, 1.11; 95% CI 1.06 –1.16) and was unchanged over time. Conclusions: Rates of reperfusion therapy, coronary angiography, and in-hospital death after MI, but not the use of aspirin and beta-blockers, vary according to race and gender, with no evidence that the differences have narrowed in recent years. Perspective: The findings are surprising considering the widespread use of the guidelines for management of MI. There is no evidence that the decreased use of reperfusion therapy and coronary angiography in women and blacks is related to a physician bias or payment method. My experience is that older white and black women, particularly widows and those without a good family support system, will refuse aggressive treatment. Is the bias mine or theirs? We clearly need more data. Melvyn Rubenfire/Kim Eagle
not impact in-hospital mortality (68% vs. 66%; p⫽0.39). Further, there was no difference in the length of ICU stay, length of hospitalization or duration of organ support between the two groups. No subgroup was identified that appeared to have either an enhanced benefit or harm from PA catheter use. The use of PA catheter was associated with complications in 10% of the patients, but none of these were fatal. Conclusions: The researchers concluded that use of PA catheters in the ICU did not impart any positive or negative survival benefit. Perspective: The use of PAC in ICUs is widely prevalent despite lack of any efficacy studies. Observational studies had raised the possibility that use of PACs may be associated with a paradoxical increase in mortality in certain populations. This and two earlier small randomized studies have not detected any mortality hazard with the use of the PAC but have also failed to establish any clinical benefit. Concerns have been raised that clinicians may not be able to correctly interpret information obtained from a PAC and thus its use may be associated with inappropriate therapeutic decision making. Further, better noninvasive monitoring provides increasingly sophisticated information and may make some of the information obtained by invasive monitoring redundant. It is, however, plausible that the use of PAC is increasingly limited to patients too ill to be impacted upon by hemodynamic manipulations. Further studies are therefore warranted to identify patient populations most likely to benefit from the use of a PAC. Hitinder Gurm
Acute Aortic Dissection Presenting With Primarily Abdominal Pain: A Rare Manifestation of a Deadly Disease Study Question: What is the morbidity and mortality of patients with acute thoracic aortic dissections who present primarily with abdominal pain? Methods: Patients with acute thoracic aortic dissection enrolled in the International Registry of acute Aortic Dissection (IRAD) were studied. The IRAD consists of 15 international referral centers in which hospital records of patients with acute aortic dissections are assessed and reviewed by physicians. Patient demographics, presenting symptoms, signs of aortic dissection, aortic pathology, and mortality were compared in patients presenting primarily with abdominal pain (group I, 46 patients, 4.6%) versus all others (group II). Results: Nine hundred ninety-two patients (mean age, 62.1⫾14.1 years; 68% male) with aortic dissection were enrolled from 1996 to 2001 in IRAD. Demographics were similar between groups I and II. When signs of aortic dissection were examined, 63% of patients in group I presented with hypertension compared to only 47% of patients in group II (p⫽0.04). Patients in group I were less likely to present with evidence of end-organ malperfusion. Overall
Assessment of the Clinical Effectiveness of Pulmonary Artery Catheters in Management of Patients in Intensive Care (PAC-Man): A Randomised Controlled Trial Harvey S, Harrison DA, Singer M, et al. Lancet 2005;366:472–7. Study Question: What is the impact of routine pulmonary artery catheter (PAC) usage on hospital mortality in patients admitted to the intensive care unit (ICU)? Methods: The investigators randomized 1041 patients admitted to 65 intensive care units (ICUs) in the United Kingdom to management with or without a PAC. Timing of PAC insertion and further therapeutic decision making was at the discretion of the treating physician. Results: Two-thirds of the patients were admitted to the ICU with medical illness, whereas a majority of the reminder were admitted after having undergone emergency surgery. Multiorgan failure was present in one-third of the cohort and 13% had respiratory failure. The use of PAC did
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Perspective: Our understanding of the presentation and evaluation of acute thoracic aortic dissection has been greatly redefined by the International Registry of acute Aortic Dissection (IRAD). This influential registry has again served to allow the current study examining the influence of abdominal pain at presentation on outcomes in patients found to have acute thoracic aortic dissection. This study highlights the deadly nature of dissection patients who present with atypical symptoms, especially abdominal pain. The delayed diagnosis seen in this group serves to further underscore the necessity of including dissection in the differential of sudden-onset abdominal pain, especially in high-risk individuals. James Froehlich
in-hospital mortality was not different between the two groups (26.1% for group I vs. 22.9% for group II, p⫽0.62). However, mortality in patients with a type B dissection, specifically following surgery for the dissection, was significantly increased in patients who presented primarily with abdominal pain (group I, 28% mortality vs. group II, 10.2% mortality; p⫽0.02). Conclusions: The researchers concluded that the study documented increased mortality in patients with acute thoracic aortic dissections who present primarily with abdominal pain, underscoring the importance of maintaining a high index of suspicion for an aortic dissection in patients who have appropriate risk factors.
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not impact in-hospital mortality (68% vs. 66%; p⫽0.39). Further, there was no difference in the length of ICU stay, length of hospitalization or duration of organ support between the two groups. No subgroup was identified that appeared to have either an enhanced benefit or harm from PA catheter use. The use of PA catheter was associated with complications in 10% of the patients, but none of these were fatal. Conclusions: The researchers concluded that use of PA catheters in the ICU did not impart any positive or negative survival benefit. Perspective: The use of PAC in ICUs is widely prevalent despite lack of any efficacy studies. Observational studies had raised the possibility that use of PACs may be associated with a paradoxical increase in mortality in certain populations. This and two earlier small randomized studies have not detected any mortality hazard with the use of the PAC but have also failed to establish any clinical benefit. Concerns have been raised that clinicians may not be able to correctly interpret information obtained from a PAC and thus its use may be associated with inappropriate therapeutic decision making. Further, better noninvasive monitoring provides increasingly sophisticated information and may make some of the information obtained by invasive monitoring redundant. It is, however, plausible that the use of PAC is increasingly limited to patients too ill to be impacted upon by hemodynamic manipulations. Further studies are therefore warranted to identify patient populations most likely to benefit from the use of a PAC. Hitinder Gurm
Acute Aortic Dissection Presenting With Primarily Abdominal Pain: A Rare Manifestation of a Deadly Disease Study Question: What is the morbidity and mortality of patients with acute thoracic aortic dissections who present primarily with abdominal pain? Methods: Patients with acute thoracic aortic dissection enrolled in the International Registry of acute Aortic Dissection (IRAD) were studied. The IRAD consists of 15 international referral centers in which hospital records of patients with acute aortic dissections are assessed and reviewed by physicians. Patient demographics, presenting symptoms, signs of aortic dissection, aortic pathology, and mortality were compared in patients presenting primarily with abdominal pain (group I, 46 patients, 4.6%) versus all others (group II). Results: Nine hundred ninety-two patients (mean age, 62.1⫾14.1 years; 68% male) with aortic dissection were enrolled from 1996 to 2001 in IRAD. Demographics were similar between groups I and II. When signs of aortic dissection were examined, 63% of patients in group I presented with hypertension compared to only 47% of patients in group II (p⫽0.04). Patients in group I were less likely to present with evidence of end-organ malperfusion. Overall
Assessment of the Clinical Effectiveness of Pulmonary Artery Catheters in Management of Patients in Intensive Care (PAC-Man): A Randomised Controlled Trial Harvey S, Harrison DA, Singer M, et al. Lancet 2005;366:472–7. Study Question: What is the impact of routine pulmonary artery catheter (PAC) usage on hospital mortality in patients admitted to the intensive care unit (ICU)? Methods: The investigators randomized 1041 patients admitted to 65 intensive care units (ICUs) in the United Kingdom to management with or without a PAC. Timing of PAC insertion and further therapeutic decision making was at the discretion of the treating physician. Results: Two-thirds of the patients were admitted to the ICU with medical illness, whereas a majority of the reminder were admitted after having undergone emergency surgery. Multiorgan failure was present in one-third of the cohort and 13% had respiratory failure. The use of PAC did
ACC CURRENT JOURNAL REVIEW December 2005
6
Perspective: Our understanding of the presentation and evaluation of acute thoracic aortic dissection has been greatly redefined by the International Registry of acute Aortic Dissection (IRAD). This influential registry has again served to allow the current study examining the influence of abdominal pain at presentation on outcomes in patients found to have acute thoracic aortic dissection. This study highlights the deadly nature of dissection patients who present with atypical symptoms, especially abdominal pain. The delayed diagnosis seen in this group serves to further underscore the necessity of including dissection in the differential of sudden-onset abdominal pain, especially in high-risk individuals. James Froehlich
in-hospital mortality was not different between the two groups (26.1% for group I vs. 22.9% for group II, p⫽0.62). However, mortality in patients with a type B dissection, specifically following surgery for the dissection, was significantly increased in patients who presented primarily with abdominal pain (group I, 28% mortality vs. group II, 10.2% mortality; p⫽0.02). Conclusions: The researchers concluded that the study documented increased mortality in patients with acute thoracic aortic dissections who present primarily with abdominal pain, underscoring the importance of maintaining a high index of suspicion for an aortic dissection in patients who have appropriate risk factors.
ACC CURRENT JOURNAL REVIEW December 2005
7