Işıl BAŞARA AKIN, Naciye Sinem GEZER, Aytaç GÜLCÜ, Mustafa Mahmut BARIŞ

Ani Başlayan Göğüs Ağrısında BT Anjiyografi ile Akut Aortik Sendrom ve Diğer Acillerin Tanı Sıklığı

Amaç: Bu çalışmada acil serviseani başlayan göğüs ağrısı şikayeti ile baş vuranve akut aortik sendrom (AAS) ön tanısı bulunan hastaların bilgisayarlıtomografi anjiyografi (BTA) sonuçlarının değerlendirilmesi amaçlanmıştır.Gereç ve Yöntem: Hastanemiz radyolojik görüntüleme arşivi retrospektifolarak taranarak, Ocak 2011-Temmuz 2013 tarihleri arasında, acil serviste anibaşlayan göğüs ağrısı şikayeti ve AAS ön tanısı ile çekilen BTA incelemeleridahil edilmiştir. Saptanan AAS’ler ve AAS dışı akut torakal ve abdominalpatolojiler kaydedilmiştir.Bulgular: Toplam 631 BTA incelemesinin 152 (%24.1) tanesinde acil torakalveya abdominal patoloji saptanmıştır. 152 acil patolojinin 27’sinde (%17.8)aort diseksiyonu, 7’sinde (%4.6) aort anevrizma rüptürü olmak üzere toplam34’ünde (%22.4) AAS görülmüştür. 79 olguda (%52) AAS dışı acil torakalpatolojiler, 26 olguda (%17.1) AAS dışı abdominal patolojiler izlenmiştir.Pnömoni (%30.3), pulmoner ödem (%9.9), pulmoner tromboemboli (PTE)(%9.2), nefrolitiazise sekonder üriner obstrüksiyon (%5.9), mezenteriklenfadenit (%3.3) ve akut kolesistit (%3.3) daha sık görülenlerdir. Ayrıcaakciğer kanseri, lenfoma ve kolon kanseri gibi primer malignitelerin nedenoluğu acil komplikasyonlar 13 (%8.6) olguda görülmüştür.Sonuç: Akut koroner sendrom ve PTE, AAS ayırıcı tanısında ilk düşünülmesigereken patolojilerdir. Ancak çok çeşitli torakoabdominal acil patolojilerinAAS’leri taklit etmesi nadir değildir. Bu çalışmada en sık görülenler pnömoni,pulmoner ödem, PTE, nefrolitiazise sekonder üriner obstrüksiyon, akutkolesistitve mezenterik lenfadenittir. Diğer bir dikkat çekici bulgu ise primermalign süreçlerin neden oluğu acil komplikasyonların sıklığıdır.

Frequency of Acute aortic Syndromes and Other Thoracoabdominal Emergencies Detected by CT Angiography in Sudden Onset Chest Pain

Objective: Acute coronary syndrome and pulmonary thromboembolism (PTE) are the pathologies to be considered in the differential diagnosis of acute aortic syndromes (AAS). However, it is not uncommon many thoracoabdominal emergencies imitating AAS. In this study, we aimed to evaluate the results of computed tomography angiography (CTA) images obtained for sudden onset chest pain in the emergency department because of a preliminary diagnosis of AAS. Methods: We retrospectively evaluated the imaging archive of our hospital for images obtained for sudden onset chest pain in the emergency department because of initial diagnosis of AAS between January 2011 and July 2013. Detected AAS and acute thoracic and abdominal pathologies were recorded. Results: Out of 631 CTA, 152 (24.1%) demonstrated thoracoabdominal emergencies. 34 of them (5.4%) were AAS. A 27 (17.8%) of the AAS’s were aortic dissection, while 7 (4.6%) of them were a ruptured aortic aneurysm. Thoracic and abdominal emergencies were detected in 79 (52%) and 26 (17.1%) of cases respectively. More common ones were pneumonia (30.3%), pulmonary edema (9.9%), PTE (9.2%), urinary obstruction secondary to nephrolithiasis (5.9%), mesenteric lymphadenitis (3.3%) and acute cholecystitis (3.3%). Urgent complications due to primary malignancies such as lung cancer, lymphoma and colon cancer were detected in 13 (8.6%) of the cases. Conclusion: In the current study, pneumonia, pulmonary edema, PTE, urinary obstruction secondary to nefrolitiasis, mesenteric lymphadenitis and acute cholecystitis were more commonly detected thoracoabdominal emergencies imitating AAS. Another remarkable finding was the frequency of urgent complications due to primary malignancies.

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Erkuş ME, Demirbağ R. Highlights from the 2014 European Society of Cardiology Guidelines for Aortic Diseases. Arch Turk Soc Cardiol 2015; 43:12- 7.
Akpınar E, Hızal M.Akut Göğüs Ağrısında Üçlü Dışlama Bilgisayarlı Tomografi Anjiyografi[Triple Exclusion Computed Tomography Angiography in Acute Chest Pain]. Trd Sem 2013;1:143-52.
Flukinger T, White CS. Multidetector computed tomography in the evaluation of chest pain in the emergency department. Semin Roentgenol 2008; 43:136-44.
Balk EM, Ioannidis JP, Salem D, Chew PW, Lau J. Accuracy of biomarkers to diagnose acute cardiac ischemia in the emergency department: a metaanalysis. Ann Emerg Med 2001; 37:478-94.
Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003; 6:933-40.
Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management, part I: from etiology to diagnostic strategies. Circulation 2003;108:628-35.
Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management, part II: therapeutic management and follow-up. Circulation 2003;108:772-8.
Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The international registry of acute aortic dissection (IRAD): new insights into an old disease. JAMA 2000;283:897-903.
Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, et al. Diagnosis and management of aortic dissection. Eur Heart J 2001;22:1642-81.
Castañer E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardó Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical features and complications. Radiographics 2003;23:93-110.
Achar SA, Kundu S, Norcross WA. Diagnosis of acute coronary syndrome. Am Fam Physician 2005; 72:119-26.
Joshi PH, Blaha MJ, Blumenthal RS, Blankstein R, Nasir K. What is the role of calcium scoring in the age of coronary computed tomographic angiography? J Nucl Cardiol 2012; 19:1226-35.
Margolis JR, Chen JT, Kong Y,Peter RH, Behar VS, Kisslo JA. The diagnostic and prognostic significance of coronary artery calcification. A report of 800 cases. Radiology 1980;137:609-16.
Heller GV,Stowers SA, Hendel RC, Herman SD, Daher E, Ahlberg AW, et al.Clinical value of acute rest technetium-99m tetrofosmin tomographic myocardial perfusion imaging inpatients with acute chest pain and non diagnostic electrocardiogram. J Am Coll Cardiol 1998;31:1011-7.
Kawahito M, Kondo M, Abe Y, Sakata J, Ikeda T, Maeba H, et al.Usefulness of technetium-99m tetrofosmin single-photon emission computed tomography for short-term risk stratification in patients with acute chest pain in the emergency room. J Cardiol 2003; 42:147-54.
Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Karkabi B, Flugelman MY, et al. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation 2007; 115:1762-8.
Sorenson HR, Olsen H. Ruptured and dissecting aneurysms of aorta; incidence and prospects of surgery. Acta Chir Scand 1964;128:644-50.
Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aorta dissection: penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999;17:637-57.
Daily PO, Truebold HW, Stinson EB, Wuerfflein RD, Shumway EN. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-47.
Khan IA, Nair CK. Clinical, diagnostic and management perspectives of aortic dissection. Chest 2002;122:311-28.
Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. ESC Committee for Practice Guidelines (CPG).Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC).Eur Heart J 2008;29:2276-315.
Ohlmann P, Faure A, Morel O, Petit H, Kabbaj H, Meyer N, et al. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Crit Care Med 2006; 34:1358-64.