Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis

The objective of this study was to understand why the diagno-sis of Acute Aortic Syndrome (AAS) is missed in the ED, and to characterise the presenting features of cases in which a diagnosis of AAS was missed. A retrospective case series cohort study was performed, identifying and analysing cases where AAS was misdi-agnosed in three UK EDs between 1st January 2011 and 31st December 2020. Forty-three cases were included, 22 of which were type A aortic dissections. The most common incorrect pre-sumed diagnoses made were acute coronary syndrome (28%), pul-monary embolism (12%) and 'non-specific chest pain' (12%). In 31 cases (72%) there was no evidence from the notes that the clin-ician had considered AAS in the differential diagnosis. In 10 cases (23%), AAS was considered, but the clinician was falsely reas-sured by atypical or resolved symptoms, clinical examination, or normal chest x-ray. We conclude that ED clinicians may miss AAS by not considering it as a possibility, being falsely reassured by atypical or resolved symptoms, or mistaking it for other more com-mon conditions. Further prospective work is necessary to establish the role of diagnostic aids and biomarkers in UK EDs.