Clinical study
Chest radiography for the diagnosis of acute aortic syndrome

https://doi.org/10.1016/j.amjmed.2003.08.030Get rights and content

Abstract

Purpose

We sought to assess the diagnostic accuracy of routine chest radiography for the acute aortic syndrome (dissection, intramural hematoma, penetrating ulcer, or nondissecting aneurysm).

Methods

During a 6-year period, 216 patients (143 men, 73 women; mean [± SD] age, 58 ± 17 years) underwent chest radiography for suspected acute aortic syndrome. Chest films were re-evaluated blindly for aortic disease, based on an overall impression using standard criteria such as widening of the aortic contour and mediastinal shadow. Findings were matched to tomographic images, anatomical inspection, or both, as the criterion standard; aortic disease was confirmed in 109 (50%) of the patients.

Results

Chest radiography had a sensitivity of 64% (70/109) and a specificity of 86% (92/107) for aortic disease. Sensitivity was 67% (38/57) for overt aortic dissection, 61% (22/36) for nondissecting aneurysm, and 63% (10/16) for intramural hemorrhage or penetrating ulcer. However, sensitivity was lower for pathology confined to the proximal aorta (47% [21/45]) than for disease involving distal aortic segments (77% [49/64]). A receiver operating characteristic curve analysis of aortic diameters failed to identify a threshold for the diagnosis of aortic disease.

Conclusion

Chest radiography is of limited value for diagnosing the acute aortic syndrome, particularly for conditions confined to the ascending aorta. Since a definitive diagnosis is required in any patient with clinically suspected acute aortic syndrome, routine chest radiography should be replaced by tomographic aortic imaging.

Section snippets

Patients

During a 6-year period, 216 patients (143 men and 73 women; mean [± SD] age, 58 ± 17 years) presented to the emergency department of the University Hospital of Hamburg-Eppendorf with suspected acute aortic disease. All patients had onset of chest pain, back pain, or both, within 14 days of arrival at the emergency department. Patients with the acute coronary syndrome or other diagnoses explaining the pain syndrome, recent trauma, or cardiovascular surgery, or who could not provide a history,

Results

Of the 216 patients, aortic dissection was diagnosed in 57 patients, nondissecting aneurysm was diagnosed in 36 patients (with contained rupture in 3 of them), and intramural hemorrhage or penetrating aortic ulcer was diagnosed in 16 patients; aortic disease was excluded in the remaining 107 patients (Table 1). A consensus decision on the presence or absence of aortic disease on chest radiography was obtained for all patients. Aortic disease was diagnosed by chest radiography with a

Discussion

This study, with blinded expert evaluation, was designed to assess the diagnostic accuracy of chest radiography among patients with suspected acute aortic syndrome. Previous studies of chest radiography assessed its value for diagnosing aortic dissection only. The 11 reports from studies that included at least 50 cases (a total of 1398 patients) had an overall sensitivity of 71% 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. For the broader diagnosis of the acute coronary syndrome, our study had an overall

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