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Institute of Cardiac Surgery Medical School, University of Bari Bari, Italy
To the Editor:
We read with interest the pattern that Rosman and colleagues (September 1998)1 have developed to take histories in patients with aortic dissection (AD). They have hypothesized that the collection of anamnestic data could contribute to a more accurate diagnosis. Moreover, they have scored some features of the typical "ripping and tearing" chest pain as quality, radiation, and sudden intensity at onset to compare, in a retrospective study, effective diagnosis and initial clinical suspicion.
This interesting and debated topic has attracted our attention due to the high number of patients with AD that we have managed in the last 5 years (176 cases between October 1993 and August 1998). This huge number of cases with a clinical or imaging diagnosis (CT scan, MRI, angiography, transthoracic or transesophageal echocardiography), which is often confirmed by either surgical inspection or autopsy examination, has contributed to a general increase in our experience both in diagnosis and management. More than 12% of these patients (Table 1 ) have been sent to our attention with an abnormal clinical scenario (mild dizziness or chest discomfort, lower limb paresthesia, hoarseness, transient ischemic attack, etc) or symptoms more suggestive of myocardial ischemia. Most of these patients did not complain about sudden chest pain, but described symptoms slowly worsening in the previous days. The contribution of technology in all of these situations has addressed our therapy and allowed us to save more people.
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We agree both with the general importance of the initial history in raising a clinical suspicion and with the diffuse tendency to quickly turn to an imaging diagnosis instead of trusting our deductive instincts. Nevertheless, due to the high mortality rate and unpredictability of this disease, we strongly believe in the interaction between physicians and machines. We do not feel comfortable in treating patients, medically or surgically, without a clear definition of this entity. A quick scanning of the patient when possible, even if risky, allows a more accurate knowledge of extension and prognosis.
The result of AD treatment is often a question of time; it does not allow a thorough analysis of the patient history and it obligates the physician to apply the right procedure in a few hours. Although it is reasonable that a clinical suspicion should have the lead in decision making, today we have resources that were not available to Morgagni, the Italian anatomist and pathologist, in the 18th century.
In the last decade, both surgical and pharmacologic therapies for AD have improved. This goal has been achieved with the participation of an even more accurate diagnosis performed by cardiologists or radiologists4 and their excellent skills in rapidly detecting the aortic wall defect. In most of the cases, according to our experience, this would have not been possible without coupling clinical suspicion and diagnostic imaging.5
Correspondence to: Stefano Schena, MD, Via delle Murge 59/A, 70124 Bari, Italy; e-mail: s.schena@usa.net
References
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