Acute aortic dissection (AAD) is the most lethal vascular emergency. AAD remains a challenge
to diagnose and to treat even for experienced practitioners. AAD identification and treatment
administration greatly improve morbidity and mortality associated to AAD. The diagnosis of
AAD is particularly challenging, due to a combination of highly heterogeneous clinical
presentation and low incidence (3-5 cases/100,000 individuals/year). Clinical guidelines
suggest that AAD should be considered in all patients presenting with chest pain, back pain,
abdominal pain, syncope or symptoms consistent with perfusion deficit, but these symptoms
account for large proportions of emergency medical visits. CT-scan is validated and
increasedly available for confirming or ruling out AAD. Stanford classification is most
current use, with two groups : type A involve the ascending aorta, type B don't involve the
ascending aorta until the arch. The majority of type A is managed surgically, but the
majority of type B is managed medically with anti-hypertensive treatment. Aortic dissection
can be classified into hyperacute (from symptom onset to 24 hours), acute (2-7 days),
subacute (8-30 days), and chronic (> 30 days). Booher et al, suggested that acute and
sub-acute aortic dissection make the majority of the mortality rate.
Mortality among patients with a Stanfond Type A dissection is 1 to 2 percent per hour, early
after symptom onset. In-hospital mortality is highly dependent on patient risk profiles
before surgery. Patient with a history of aortic valve replacement, a migrating chest pain, a
tamponade, an hypotension or a limb ischemia are associated to a higher in-hospital
mortality.
Time between symptoms onset and treatment initiation is crucial. The diagnosis can be
suspected by the family physician. In France, diagnosis can be also suspected by the MICU
(Mobile Intensive Care Unit). An anti-hypertensive treatment can be rapidly initiated before
the arrival by the ED, and the diagnosis is confirmed by CT-scan. In the Harris' study,
median time from arrival at the emergency department to diagnosis and from diagnosis to
surgery were 4.3 hours. To our knowledge no study investigated the pre-hospital phase,
especially the impact of the methods and vectors used. A better understanding of the chain of
care from symptoms onset to surgery could lead to a reduction of morbi-mortality. Our study
aimed the objective to describe the chain of care of patients with AAD in the ED of eight
hospitals centers of area of Franche-Comté (France) between 2010 and 2019.