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Three Part Question

In [patients with acute chest pain] what [is the sensitivity of abnormal peripheral pulses] for [diagnosing acute dissection of the thoracic aorta]

Clinical Scenario

A 63 year old man presents to the emergency department with a one hour history of central chest pain of sudden onset. ECG reveals ST elevation in his inferior leads. He has no obvious contra-indications to thrombolysis in his history but you wish to ensure he has no evidence of a dissecting thoracic aneurysm before giving streptokinase. To keep your door-to-needle time below 20 minutes you wonder whether excluding a pulse deficit clinically is sensitive enough to avoid waiting for X-ray.

Search Strategy

Medline 1966-05/04 using the OVID interface.
([disect$.af. OR dissect$.af] AND [aorta.af OR aortic.af] AND [thoracic.af OR chest.af OR thorax.af OR ascend$.af OR arch.af OR descend$.af] AND [pulse.af OR puls$.af]) LIMIT to human AND English language

Search Outcome

Altogether 89 papers found. One was a systematic review of the literature up to 2000. All relevant papers except 2 that post-dated it were included in this review. These three papers are summarised in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Klompas M, 2000, USA	16 papers pooling sensitivity of pulse deficit in 1586 patients	Meta-analysis	Sensitivity	31% (95% CI 24-39%)	Majority of studies lacked control group. Majority retrospective analysis of signs in patients with known dissection
Bossone E et al, 2002 Italy	513 patients with type A aortic dissection confirmed on imaging, surgery or post-mortem	Mix of prospective diagnostic trial and retrospective review of case notes	Sensitivity	30%
			Mortality	24.7% no pulse deficit
Mehta RH et al, 2002, International	550 patients with type A dissection in an international registry	Retrospective analysis of registry	Sensitivity	30.1%	Small study considering 5 countries involved Retrospective review of diagnosed patients May include patients from Bossone et al paper

Comment(s)

Few studies use a control group and use a top-down approach of assessing only patients with a dissection. This makes calculation of likelihood ratios difficult. There is yet to be a blinded bottom up trial of pulse deficit in thoracic aorta dissection. Interestingly it appears that pulse deficit may have use in the risk assessment of dissection.

Clinical Bottom Line

Pulse deficit has a sensitivity of around 30% in dissecting thoracic aortic aneurysm. This is far too low to be considered suitable as a SnOut and other investigations are required.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA 2002;287(17):2262-72.
2. Bossone E, Rampoldi V, Nienaber CA, et al. Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection. Am J Cardiol 2002;89(7):851-5.
3. Mehta RH, O'Gara PT, Bossone E, et al. Acute Type A Aortic Dissection in the Elderly: Clinical Characterisics, Management, and Outcomes in the Current Era. J Am Coll Cardiol 2002;40(4);685-692.