A new guideline aimed at helping clinicians identify the difficult-to-diagnose acute aortic syndrome has been recently published in the Canadian Medical Association Journal (CMAJ).

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Acute aortic syndrome (AAS) is a life-threatening condition that underlies one in 2,000 visits to the emergency department for severe chest or back pain. The rate of misdiagnosis is estimated to be as high as 38 percent and the risk of death can increase 2 percent for every hour of delay in diagnosis. The target audience for the guideline includes emergency physicians, primary care clinicians, internists, radiologists, vascular surgeons, cardiothoracic surgeons, and critical care physicians as well as decision-makers and patients.

"This guideline is intended as a resource for practising clinicians, both as an evidence base and a guide to investigation for this high-risk aortic catastrophe," writes Dr Robert Ohle, an emergency physician at the Health Science North Research Institute, Northern Ontario School of Medicine, Sudbury, Ontario with coauthors.

Recommendations include an assessment of risk factors, pain features and high-risk physical exam findings to establish pre-test disease risk. The risk factors include connective tissue disease, aortic valve disease, recent aortic procedure, aortic aneurysm and family history of AAS while high-risk pain includes sudden-onset or thunderclap pain, severe or worst-ever pain, tearing, migrating or radiating pain.

High-risk physical exam findings include aortic regurgitation, pulse deficit, neurological deficit and hypotension/pericardial effusion. The guideline for diagnostic strategy recommends no investigation of those at low risk, D-dimer testing of people of moderate-risk and immediate electrocardiogram-gated computed tomography (CT) of the aorta for high-risk individuals. To help with decision-making, the guideline group created a clinical decision aid to accompany the guideline. The guideline can be adapted by clinicians based on local circumstances as a one-size-fits-all approach may not be feasible. "This document may serve as a basis for adaption by local, regional or national guideline groups," write the authors. 

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