O-205 - INITIAL SYMPTOMATOLOGY AND CLINICAL PRESENTATION IN VERIFIED RUPTURED ABDOMINAL AORTIC ANEURYSMS. TIME FOR AN EXPANDED TRIAD?

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Bergmark P. (Emergency Department, Karolinska University Hospital Stockholm, Sweden. ~ Stockholm ~ Sweden) , Talvitie M. (Department of Vascular Surgery, Karolinska University Hospital Stockholm, Sweden ~ Stockholm ~ Sweden) , Roy J. (Department of Vascular Surgery, Karolinska University Hospital Stockholm, Sweden ~ Stockholm ~ Sweden) , Hultgren R. (Department of Vascular Surgery, Karolinska University Hospital Stockholm, Sweden ~ Stockholm ~ Sweden)
Introduction:
Patients with ruptured abdominal aortic aneurysms (rAAA) suffer a devasting immediate high mortality rate as well as short term mortality when admitted1,2. The possible misdiagnosis of rAAA contributes to a delayed treatment and a higher risk of mortality1. The symptomatology in patients with rAAA is complex and challenging, 25-50% will presumably fulfill the criteria of the standard triad of symptoms (STS)2-5. An updated diagnostic classification system could possibly increase the chance of a rapid and correct rAAA diagnosis in emergency care. The primary objective of this study was to investigate the initial symptomatology for patients with verified rAAA. The secondary objective was to compare the STS with an expanded definition of triad symptoms.
Methods:
A population based retrospective multicenter study of electronic medical records (EMR) collected from patients with verified rAAA admitted to the hospital from January 2010 to October 2021 (ICD code 171.3). The STS was defined as abdominal pain, syncope, and a pulsatile abdominal mass. The modified expanded classification system included similar and related symptoms commonly registered in the clinical setting of rAAA, the Modified-Abdominal Aortic Aneurysm-Rupture-Symptoms -Score (MARS-Score). Figure 1. MARS mirrors and expands the STS, such as "associated pain" (abdominal, back, flank, groin, chest), "hypovolemic symptoms" (syncope, dizziness, nausea, vomiting and dyspnea) and the "pulsatile abdominal mass "(findings at ultrasounds in the prehospital setting or emergency department). The STS and its modified expansion, the MARS Score is shown in Figure 1. Continuous variables were reported as mean and standard deviation, and t tests were used to test for differences. Categorical data were reported in proportions and statistical significance was tested with Fischer's test. The study was approved by the Swedish Ethical Review Authority.
Results:
Most patients were men (167/216, 77%) and the mean age for all patients was 78 years. The patients had the expected distribution of comorbid conditions (data not shown). The mean aortic diameter at rupture was 78 mm (68 in women, 81 in men, p >0.001). Most of the admitted patients were treated (200/216, 93%), most with open repair (104/200, 52%). A small fraction of the 216 patients with rAAA presented with all three of the STS (29/216, 13%), 35% with two STS and 43% with one STS. Figure 2. When applying the MARS-Score; 35% fulfilled three criteria, 47% two MARS and 17% one MARS. Patients that fulfill 2 or 3 scores on STS vs MARS are 50 vs 85% (p<0.001). Fulfillment of null or 1 symptom was 50% for STS vs 15% in MARS. Figure 2 A and B. The mortality rate for all admitted patients was 33 % within 30 days, 44% in 1 year (39 % women, 32% men at 30 days, p= 0.37, 47% vs 44% at 1 year, p=0.78).
Conclusion:
Misdiagnosis of rAAA patients is associated with a worse outcome. A majority of all patients with rAAA did not present with all STS, but by adding a broader clinically relevant spectrum of clinical findings to the STS, an increased number of patients fulfilled the MARS-triad. Supportive diagnostic mnemonics and tools, MARS scoring, did increase the precision of a correct rAAA diagnosis. Although retrospectively collected, the results suggest that by applying a modified symptom score for rAAA, i.e., MARS-Score, a timelier treatment could be administered for this patient group with a very high fatality rate. Validation of the MARS at other centers is necessary and pending.
References:
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