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Epidemiology, mortality and miss rate of acute aortic syndrome in Ontario, Canada: a population-based study

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Abstract

Introduction

Acute aortic syndrome (AAS) is a life-threatening emergency. It describes three distinct diagnoses: acute aortic dissection, acute intramural hematoma and penetrating atherosclerotic ulcer. There are currently no accurate estimates for incidence, mortality or misdiagnosis. Our objectives were to determine the incidence, mortality and miss rate of acute aortic syndrome in the emergency department (ED).

Methods

A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of acute aortic syndrome were identified between 2003 and 2018 using a validated algorithm based on ICD-10 codes and death. Incidence (number of cases/population of Ontario), mortality, and miss rate were calculated. Miss rate was defined as when a patient was seen in the ED within 14 days prior to an acute aortic syndrome diagnosis with a presenting complaint consistent with acute aortic syndrome.

Results

There were 1299 cases of acute aortic syndrome over the study period [age mean (SD) 68.03 ± 14.70; female (n = 500, 38.5%); rural areas (n = 111, 8.6%)]. The overall annual incidence for acute aortic syndrome was 0.61 per 100,000. One year mortality decreased from 47.4 to 29.1%. ED mortality was 14.9%. In the 14 days prior to diagnosis 12.5% of patients were seen in the ED with a presentation consistent with acute aortic syndrome.

Conclusions

Annual incidence of acute aortic syndrome was found to be lower than other population-based studies. Also, the burden of mortality is seen in the ED. Education initiatives should focus on the identification of acute aortic syndrome in the ED to address mortality and miss rate.

Résumé

Introduction

Le syndrome aortique aigu (SAA) est une urgence qui met la vie en danger. Il décrit trois diagnostics distincts: dissection aortique aiguë, hématome intramural aigu et ulcère athéroscléreux pénétrant. Il n'existe actuellement aucune estimation précise de l'incidence, de la mortalité ou des diagnostics erronés. Nos objectifs étaient de déterminer l'incidence, la mortalité et le taux d'échec du syndrome aortique aigu dans le service des urgences (SU).

Méthodes

Une étude de cohorte rétrospective basée sur la population a été réalisée à partir de données liées anonymement pour les résidents de l'Ontario, Canada. Les cas incidents de syndrome aortique aigu ont été identifiés entre 2003-2018 à l'aide d'un algorithme validé basé sur les codes CIM-10 et les décès. L'incidence (nombre de cas/population de l'Ontario), la mortalité et le taux d'absence ont été calculés. Le taux d’omission a été défini comme le cas où un patient a été vu à l’urgence dans les 14 jours précédant un diagnostic de syndrome aortique aigu et que la plainte était conforme au syndrome aortique aigu.

Résultats

Il y a eu 1 299 cas de syndrome aortique aigu pendant la période d'étude (âge moyen (ET) 68,03 ±14,70 ; femmes (n = 500, 38,5 %) ; zones rurales (n = 111, 8,6%)). L'incidence annuelle globale du syndrome aortique aigu était de 0,61 pour 100 000. La mortalité à un an a diminué de 47,4 % à 29,1 %. La mortalité aux urgences était de 14,9 %. Au cours des 14 jours précédant le diagnostic, 12,5 % des patients ont été vus aux urgences avec une présentation compatible avec le syndrome aortique aigu.

Conclusions

L'incidence annuelle de syndrome aortique aigu s'est avérée inférieure à celle d'autres études basées sur la population. En outre, le poids de la mortalité est observé aux urgences. Les initiatives de formation devraient se concentrer sur l'identification des syndrome aortique aigu aux urgences afin de réduire la mortalité et le taux d'échec.

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Data availability

We wish to acknowledge the data support services at Health Science North.

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Acknowledgements

This study was supported by the Institute of Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts of this report are based on Ontario Registrar General (ORG) information on deaths, the source of which is Service Ontario. The views expressed therein are those of the authors and do not necessarily reflect those of ORG or the Ministry of Government Services.

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Authors and Affiliations

  1. The Department of Emergency Medicine, Health Science North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada

    Robert Ohle, David W. Savage, Joe Caswell & Michael Conlon

  2. The Department of Emergency Medicine, Northern Ontario School of Medicine, Thunder Bay, ON, Canada

    David W. Savage, Joe Caswell & Michael Conlon

  3. Department of Critical care, Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, ON, Canada

    David W. Savage, Sarah McIsaac, Joe Caswell & Michael Conlon

  4. Ottawa Hospital Research Institute, Ottawa, ON, Canada

    David W. Savage, Krishan Yadav, Joe Caswell & Michael Conlon

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  1. Robert Ohle
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Contributions

JC performed the analysis, provided methodology input and contributed to the manuscript. RO was responsible for study design and manuscript preparation. KY provided methodology input and manuscript preparation. MC and DWS provided methodology input and were content experts in administrative data. SM provided methodology input and oversight in addition to manuscript editing. RO acts as a guarantor for the accuracy and integrity of the manuscript.

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Correspondence to Robert Ohle.

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Ohle, R., Savage, D.W., McIsaac, S. et al. Epidemiology, mortality and miss rate of acute aortic syndrome in Ontario, Canada: a population-based study. Can J Emerg Med 25, 57–64 (2023). https://doi.org/10.1007/s43678-022-00413-x

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