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      Clinical recognition of acute aortic dissections: insights from a large single-centre cohort study

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          Acute aortic dissection (AD) requires immediate treatment, but is a diagnostic challenge. We studied how often AD was missed initially, which patients were more likely to be missed and how this influenced patient management and outcomes.


          A retrospective cohort study including 200 consecutive patients with AD as the final diagnosis, admitted to a tertiary hospital between 1998 and 2008. The first differential diagnosis was identified and patients with and without AD included were compared. Characteristics associated with a lower level of suspicion were identified using multivariable logistic regression, and Cox regression was used for survival analyses. Missing data were imputed.


          Mean age was 63 years, 39% were female and 76% had Stanford type A dissection. In 69% of patients, AD was included in the first differential diagnosis; this was less likely in women (adjusted relative risk [aRR]: 0.66, 95% CI: 0.44–0.99), in the absence of back pain (aRR: 0.51, 95% CI: 0.30–0.84), and in patients with extracardiac atherosclerosis (aRR: 0.64, 95% CI: 0.43–0.96). Absence of AD in the differential diagnosis was associated with the use of more imaging tests (1.8 vs. 2.3, p = 0.01) and increased time from admission to surgery (1.8 vs. 10.1 h, p < 0.01), but not with a difference in the adjusted long-term all-cause mortality (hazard ratio: 0.76, 95% CI: 0.46–1.27).


          Acute aortic dissection was initially not suspected in almost one-third of patients, this was more likely in women, in the absence of back pain and in patients with extracardiac atherosclerosis. Although the number of imaging tests was higher and time to surgery longer, patient outcomes were similar in both groups.

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          The online version of this article (doi:10.1007/s12471-016-0921-8) contains supplementary material, which is available to authorized users.

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          Most cited references 27

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          Review: a gentle introduction to imputation of missing values.

          In most situations, simple techniques for handling missing data (such as complete case analysis, overall mean imputation, and the missing-indicator method) produce biased results, whereas imputation techniques yield valid results without complicating the analysis once the imputations are carried out. Imputation techniques are based on the idea that any subject in a study sample can be replaced by a new randomly chosen subject from the same source population. Imputation of missing data on a variable is replacing that missing by a value that is drawn from an estimate of the distribution of this variable. In single imputation, only one estimate is used. In multiple imputation, various estimates are used, reflecting the uncertainty in the estimation of this distribution. Under the general conditions of so-called missing at random and missing completely at random, both single and multiple imputations result in unbiased estimates of study associations. But single imputation results in too small estimated standard errors, whereas multiple imputation results in correctly estimated standard errors and confidence intervals. In this article we explain why all this is the case, and use a simple simulation study to demonstrate our explanations. We also explain and illustrate why two frequently used methods to handle missing data, i.e., overall mean imputation and the missing-indicator method, almost always result in biased estimates.
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            2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).

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              2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.


                Author and article information

                [1 ]ISNI 0000 0001 0547 5927, GRID grid.452600.5, Department of Cardiology, , Isala, ; Zwolle, The Netherlands
                [2 ]ISNI 0000000090126352, GRID grid.7692.a, Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, , University Medical Center Utrecht, ; Utrecht, The Netherlands
                [3 ]ISNI 0000 0001 0547 5927, GRID grid.452600.5, Department of Cardiothoracic Surgery, , Isala, ; Zwolle, The Netherlands
                [4 ]ISNI 0000000090126352, GRID grid.7692.a, Department of Anaesthesiology, , University Medical Center Utrecht, ; Utrecht, The Netherlands
                [5 ]ISNI 0000 0001 0547 5927, GRID grid.452600.5, Department of (Thoracic) Anaesthesia and Intensive Care, , Isala, ; Zwolle, The Netherlands
                [6 ]ISNI 0000 0004 0399 8953, GRID grid.6214.1, MIRA Institute for Biomedical Technology and Technical Medicine, , University of Twente, ; Enschede, The Netherlands
                Neth Heart J
                Neth Heart J
                Netherlands Heart Journal
                Bohn Stafleu van Loghum (Houten )
                23 November 2016
                23 November 2016
                March 2017
                : 25
                : 3
                : 200-206
                © The Author(s) 2016

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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