The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies

The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies Chang Xiaoxin, Yao Jianhua, Xu Yawei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1479700/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: The research of the sensitivity and specificity point-of-care testing (POCT) of D-dimer as a diagnostic protocol for differential diagnosis of TAAS (hereafter as TAAS) mimicking ST-elevated myocardial infarction (STEMI) with regular STEMI in the emergency department is limited. Methods: Full medical information of 32 patients confirmed TAAS and 527 patients confirmed STEMI from January 1 st , 2016 to October 1 st , 2021 were retrospectively analyzed in Shanghai tenth People’s Hospital of Tongji University. Results: The baseline characteristics of two groups of patients were well-balanced post propensity score matching (PSM) analysis, and each group had 32 patients enrolled. Patients in the STEMI group had higher positive cardiac troponin I (cTNI) (0.174ng/mL vs. 0.055ng/mL, P=0.008) results but lower D-dimer (0.365ug/mL vs. 31.50ug/mL, P<0.001) results than the TAAS group. The AUC values were 0.998 (95% CI:0.993-1.000) for the D-dimer, and the D-dimer cutoff value of 2.155ug/mL had the best sensitivity of 100% and specificity of 96.9% in the TAAS group. No significant correlation between the D-dimer concentration and the time from symptom onset to first medical contact in both groups (TAAS group: r=-0.248, P=0.170; STEMI group: r=-0.159, P=0.383). The total in-hospital mortality for the patients with TAAS presenting as STEMI was 62.5% (20/32). The mortality rate for TAAS patients confirmed by CTA was significantly lower (40% vs. 82.4%, P=0.014) than the mortality rate for TAAS patients confirmed by CAG and had a longer average survival time (log-rank=0.015) but less peri-surgical complications, especially gastrointestinal hemorrhage (0.00% vs. 55.6%, P<0.001). CTA diagnosis can reduce the mortality rate by 67.5% (95%CI:0.124-0.850, P=0.16). Conclusions: The POCT D-dimer can exclude TAAS mimicking STEMI from regular STEMI prior to reperfusion therapy. Stanford type A aortic syndrome Coronary reperfusion therapy D-dimer ST-segment elevated myocardial infarction. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Stanford type A aortic syndrome (TAAS) extends to the ostium of the coronary artery may lead to acute coronary occlusion, thus leading to acute coronary syndrome (ACS) and mimicking as STEMI in electrocardiography examination. It is a life-threatening acute vascular disease that is not easily detectable because the primary electrocardiographic (ECG) presentation will make physicians ignore the atypical clinical manifestations and lead to misdiagnosis in the Emergency department (ED). Methods include computed tomography (CT), transesophageal echocardiography (TEE), transthoracic echocardiography (TTE), magnetic resonance imaging (MRI), and point-of-care ultrasound (POCUS) are used to exclude the TAAS in STEMI patients in clinical practice when there is a suspicion. While in ED, TAAS might be ignored and misdiagnosed because definitive imaging may delay the reperfusion time and regular STEMI happens more often. Therefore, it is crucial to find a reliable, fast method to differentiate whether the STEMI is secondary to TAAS and to reduce misdiagnosis. Previous studies have found that D-dimer concentrations can be elevated in TAAS and many other diseases, despite its low specificity for the condition, we found that POCT of D-dimer is a simple and efficient method for detecting and discriminating acute aortic syndrome with ST-elevated myocardial infarction in the ED and thus leading to the important clinical decision making. Here, we retrospectively analyzed the clinical characteristics, lab tests, and outcomes of the confirmed patients diagnosed with STEMI and STEMI secondary to TAAS, hoping this study could provide deep insight into such conditions and offered an effective and fast method to reduce such misdiagnosis and improve the prognosis of these patients. Materials And Methods Patients This is a one-center retrospective study. 34 patients who confirmed STEMI secondary to TAAS and 551 STEMI patients in ED enrolled in the study between January 1st, 2017 and October 1st 2021 were evaluated. 24 STEMI patients and 2 TAAS patients were excluded from the study for the lack of the POCT of D-dimer or cardiac infarct biomarker results in the ED. Stanford type A aortic syndrome was defined as intramural hematoma or aortic dissection involvement of the ascending aorta and aortic arch. Enhanced computed tomography (CTA) or coronary angiography (CAG) confirmed the diagnosis of TAAS. The diagnosis of STEMI was based on the latest criteria established by the American College of Cardiology and European Society of Cardiology, including: (1) chest pain lasting for over 30 min, (2) at least two contiguous leads with ST-segment elevation 2.5 mm in men < 40 years, 2mm in men over 40 years, or 1.5 mm in women in leads V2–V3 and/or1mm in the other leads, (3) an increase of cardiac biomarker values with at least one value above the 99th percentile of the upper reference limit. And other ECG signs of coronary artery occlusion like De winter syndrome were also included. Data collection After approval by the Clinical Ethics Committee (CEC) of the Shanghai Tenth People’s Hospital, two independent physicians retrospectively collected and reviewed the general clinical information, demographics, treatment records, and essential time points according to standards. POCT results, including cTNI, myoglobin (Myo), creatine kinase–myocardial band (CK-MB), brain natriuretic peptide (BNP), D-dimer (DD) were recorded. POCT results were available within 15 minutes with the TRIAGE platform assay panels (Alere, San Diego, CA, USA). The following assay results were predefined to be positive on either blood draw: troponin I 0·05 ng/mL or greater, CK-MB 4·3 ng/mL or greater, Myo concentration of 108 ng/mL or greater, BNP 100pg/mL or greater, and D-dimer 600ng/mL or greater. The point cutoffs were based on manufacturer recommendations, with an elevated result defined as any detectable concentration of results. Statistical analysis The frequency and percentage of the categorical data were determined. Continuous variables were presented as the 25% and 75% percentiles, median, mean and standard deviation (SD), depending on whether the data were normally distributed. A Mann-Whitney U test, chi-square, the Fischer exact or t-test were used to analyze the difference. A value of p < 0.05 was considered being significant. Propensity score matching (PSM) was used for calculating variables included sex, age, hypertension, coronary heart disease, smoking, diabetes mellitus, Marfan syndrome, previous percutaneous coronary intervention (PCI), previous coronary artery disease, previous myocardial infarction, known aneurysm, and hyperlipidemia to balance heterogeneity in demographics. The 1:1 PSM was applied to create the matched TAAS group and STEMI group with a caliper distance of 0.1. After PSM, the differences between the two groups were compared again using the aforementioned statistical methods. Receiver operating characteristic (ROC) curves were constructed after calculation of the sensitivity for the matched TAAS group to determine the best cutoff value with a 95% confidence interval (CI). The Kaplan-Meier estimates of the mortality rates in both groups are reported along with the corresponding hazard ratios (HR) and 95% CIs. All statistical analyses were performed using SPSS Statistics, version 26 (Armonk, NY, USA). Results Baseline Characteristics Detailed demographics are displayed in Table 1 . 527 STEMI patients and 32 TAAS patients were finally enrolled in the study from January 1st, 2016 to October 1st, 2021. Male patients accounted mainly in both TAAS and STEMI groups (78.1% vs. 82.0%, P = 0.584). Compared with the STEMI group, TAAS group had similar age (64[59–66] years vs. 66[61–73] years, P = 0.130), similar proportions of smokers (90.6% vs. 90.5%, P = 0.983), of patients with previous history of PCI (12.5% vs. 13.3%, P = 0.899), of patients with hyperlipidemia (56.3% vs. 53.7%, P = 0.779), of patients with hypertension (87.5% vs. 90.7%, P = 0.548), and of patients with coronary heart disease (25.0% vs. 26.6%, P = 0.845), but of more patients with known aortic aneurysm (9.4% vs. 2.8%, P < 0.05) based on the medical history. After 1:1 PSM analysis, each of 32 patients in the TAAS-group and the STEMI-group was extracted, and baseline characteristics were well balanced between the two groups. Table 1 Demographics and characteristics of the patients Pre-PSM Post-PSM Variable TAAS group (n = 32) STEMI group (n = 527) P- value TAAS group (n = 32) STEMI group (n = 32) P-value Age (years) 64[59,66] 66[61,73] 0.130 64[59,66] 69[59.5,75.5] 0.053 Men 25(78.1%) 432(82.0%) 0.584 26(81.3%) 25(78.1%) 0.756 History of tobacco (n, %) 29(90.6%) 477(90.5%) 0.983 29(90.6%) 29(90.6%) 1 Diabetes mellitus 7(21.9%) 154(29.2%) 0.719 13(40.6%) 9(28.1%) 0.292 Referred from subordinate hospitals 6(18.8%) 108(20.5%) 0.812 6(18.8%) 6(18.8%) 1 First consultation at our hospital 26(81.3%) 445(79.5%) 0.812 26(81.3%) 26(81.3%) 1 Risk factors and characteristics (n, %) History of hypertension 28(87.5%) 478(90.7%) 0.548 28(87.5%) 28(87.5%) 1 Marfan syndrome 0(0%) 0(0%) 1.000 0(0%) 0(0%) 1 Known aortic aneurysm 3(9.4%) 15(2.8%) 0.042 1(3.1%) 3(9.4%) 0.302 Previous history of PCI 4(12.5%) 70(13.3%) 0.899 4(12.5%) 4(12.5) 1 Previous atherosclerostic coronary artery disease 8(25.0%) 140(26.6%) 0.845 9(28.1%) 8(25%) 0.777 Peripheral artery disease 1(3.1%) 25(4.7%) 1.000 1(3.1%) 1(3.1%) 1 Previous myocardio infarction 0(0.0%) 12(2.3%) 0.814 0(0%) 0(0%) 1 Renal dysfunction 1(3.1%) 32(5.9%) 0.492 2(6.3%) 1(3.1%) 0.554 Hyperlipidemia 18(56.3%) 283(53.7%) 0.779 18(56.3%) 18(56.3%) 1 Cold sweats 26(81.3%) 406(77%) 0.581 26(81.3%) 26(81.3%) 1 Data are presented as the median [interquartile range] or no. (%) of patients. Clinical Data The clinical characteristics of these patients were also summarized in Table 2. Anterior chest pain was the most common initial presenting symptom among the TAAS and STEMI groups (28.1% vs. 30.2%, P = 0.226), subsequent by syncope (25.0% vs. 19.4%, P = 0.435) in PSM analysis. In the TAAS group, 7 (21.9%) patients also suffered from abdominal as well as anterior chest pain, 4 (12.5%) were sent to the hospital for cardiogenic shock and 1 (3.1%) had no other symptoms except abdominal pain. Differences in initial symptoms’ presentations were not significant between the 2 groups, and patients in both groups had normal blood pressure (105mmHg vs. 105mmHg, P = 0.543). Even patients in the STEMI group had more heartbeats (78 bpm vs. 60 bpm, P = 0.011) per minute, the result was of no clinical specificity. Table 2. Clinical symptoms and ECG presentations Pre-PSM Post-PSM Variable TAAS group (n=32) STEMI group (n=527) P- value TAAS group (n=32) STEMI group (n=32) P-value Clinical symptoms Abdinal pain + syncope 0(0%) 11(2.1%) 1 0(0%) 1(3.1%) 1 Anterior chest pain 9(28.1%) 159(30.2%) 0.806 9(28.1%) 5(15.6%) 0.226 Posterior chest pain 0(0%) 11(2.1%) 0.409 0(0%) 1(3.1%) 1 Back pain + syncope 0(0%) 5(0.9%) 1 0(0%) 0(0%) 1 abdomina pain 1(3.1%) 29(5.5%) 0.865 1(3.1%) 3(9.4%) 0.606 Chest pain + back pain 1(3.1%) 9(1.7%) 1.0 1(3.1%) 0(0%) 1 Cardiogenic shock 4(12.5%) 45(8.5%) 0.442 4(12.5%) 3(9.4%) 1 Chest pain + syncope 2(6.3%) 24(4.6%) 0.992 2(6.3%) 3(9.4%) 1 Syncope 8(25.0%) 102(19.4%) 0.435 8(25%) 9(28.1%) 0.777 Persistent or intermittent chest tightness 0(0%) 30(5.7%) 0.325 0(0%) 4(12.5%) 0.113 Anterior pain + abdmina pain 7(21.9%) 98(18.6%) 0.645 7(21.9%) 3(9.4%) 0.302 Different presentations of ST-segments elevation in ECG II, III, AVF leads 20(62.5%) 201(38.1%) 0.006 20(62.5%) 13(40.6%) 0.08 V1-V3 leads 2(6.3%) 45(8.5%) 0.651 2(6.3%) 3(9.4%) 1.000 V1-V5 leads 5(12.5%) 31(5.9%) 0.261 4(12.5%) 1(3.1%) 0.352 V3-V5 leads 0(0%) 190(36.1%) 0.000 0(0%) 13(40.6%) 0.000 V7-V9 leads 0(0%) 4(0.8%) 1.000 0(0%) 2(6.3%) 0.492 V3R-V4R leads 0(0%) 7(1.3%) 1.000 0(%) 0(0%) 1 AVR lead 1(3.1%) 16(3.1%) 1.000 1(3.1%) 0(0%) 1 I, AVL leads 0(0%) 25(4.7%) 0.388 0(0%) 0(0%) 1 De Winter Syndrome 1(3.1%) 7(1.3%) 0.949 1(3.1%) 0(0%) 1 New onset LBBB 0(0%) 1(0.2%) 1.000 0(0%) 0(0%) 1 Physical examination Systolic pressure 105[100,124] 105[100,120] 0.415 105[100,124] 105[95,122] 0.543 Diastolic pressure 60[55,65] 60[55,65] 0.676 60[55,65] 57[54,65] 0.566 Heart rate 60[51.5,85] 78[75,84] 0.000 60[51.5,85] 78[71,83] 0.011 Respiration rate 22[20,23.5] 22[18,23] 0.042 22[20,23.5] 22[18,23] 0.237 Data are presented as the median [interquartile range] or no. (%) of patients. The median time of symptom onset to first medical contact was 85 minutes and 180 minutes and the median first medical contact time to ECG examination time was 2 minutes and 3 minutes in the TAAS group and STEMI group, respectively. Among the 32 patients in the TAAS group, 20 patients had ST-segments elevation in II, III, AVF leads, and 4 patients combined with level III atrioventricular block. While it made no difference in most types of elevation in the ECG except more patients in the STEMI group could have the V3-V5 leads ST-segments elevation. Laboratory test and POCT results All patients enrolled had point-of-care testing. The median time of reports releasing time was 17 minutes in the TAAS group and 26 minutes STEMI group post PSM analysis. In PSM analysis, patients in the STEMI group had higher positive cTNI (0.174ng/mL vs. 0.055 ng/mL, P = 0.008) results than the TAAS group, but CK-MB (9.35ng/mL vs. 5.02ng/mL, P = 0.151) and Myo (106.00ng/mL vs. 57.16ng/mL, P = 0.055) made no significant differences between the 2 groups. While patients in the TAAS group had extremely higher D-dimer (31.500ug/mL vs. 0.365ug/mL, P < 0.001) and LDH (527.5U/L vs.350.0U/L, P < 0.05) results than the STEMI group. The concentrations of leukocyte count (WBC), platelet (PLT), hemoglobin (Hb), hs-CRP (CRP), and serum creatinine were not significantly different between the two groups (Table 3.). Table 3. TIMEs and lab tests in ED Pre- PSM Post-PSM variable TAAS group (n=32) STEMI group (n=527) P-value TAAS group (n=32) STEMI group (n=32) P-value Time description (minutes) Time from symptoms onset to admission 85[55,175] 180[120,250] 0.000 85[55,175] 180[120,300] 0.001 Time from admission to ECG 2[1,3] 3[2,5] 0.000 2[1,3] 3[2,5] 0.001 Time from admission to D-dimer result 17[15,26.5] 26[22,27] 0.000 17[15,26.5] 26[21,27] 0.019 Lab test results Myoglobin (ng/mL) 296.45±592.13 439.57 ±560.53 0.000 57.16[25.5,306] 106.5[56.08,481.25] 0.055 CK-MB (ng/mL) 5.02[3.11,7.49] 10.61[3.31,63.93] 0.012 5.02[3.11,7.49] 9.35[3.15,54.65] 0.151 LDH (U/L) 527.5[415.5,727] 566[393,984] 0.602 527.5[415.5,727] 350[240,524.50] 0.007 D-dimer (ug/mL) 31.5[4.77,50.00] 0.44[0.26,0.83] 0.000 31.5[4.77,50.55] 0.365[0.23,0.715] 0.000 cTNI (ng/mL) 0.055[0.008,0.109] 0.177[0.455,0.87] 0.000 0.055[0.008,0.109] 0.174[0.026,0.875] 0.008 WBC (×10 9 /L) 12.00[9.06,14.00] 10.48[8.09,13.46] 0.188 12.00[9.06,14.00] 11.6[8.53,14.00] 0.941 PLT (×109/L) 256[219.5,293.0] 225[180,278] 0.018 256[219.5,293] 251[211.5,292] 0.726 Hemoglobin(g/L) 142.5[129.0,158.5] 140[129,158] 0.668 142.5[129,158] 140[128.5,158.5] 0.814 Hs-CRP (mg/L) 3.39[1.56,15.73] 5.55[1.92,12.00] 0.682 3.39[1.56,15.73] 3.71[1.81,20.63] 0.682 Serum creatinine (umol/L) 89[67.00,106.00] 71[56.8,88] 0.015 89[67,106] 72.9[56.45,106.8] 0.394 Data are presented as the median [interquartile range], mean ± standard deviation or no. (%) of patients. The sensitivities for the TAAS of each cutoff value were calculated and used to construct the ROC curves (Fig. 1 ). The AUC values were 0.998 (95% CI:0.993-1.000) for the D-dimer, 0.695 (95% CI: 0.562–0.828) for the LDH, 0.308 (95% CI: 0.176–0.439) for the cTNT, 0.396 (95% CI: 0.252–0.539) for the CK-MB, 0.360 (95% CI:0.223–0.498) for the Myo,0.470 (95% CI:0.328–0.612) for the hs-CRP, 0.505 (95% CI:0.363–0.648) for the WBC. And the D-dimer cutoff value of 2.155ug/mL had the best sensitivity of 100% and 96.9% of specificity. No significant correlation between the -D-dimer concentration and the time from symptom onset to first medical contact in both groups (TAAS group: r=-0.248, P = 0.170; STEMI group: r=-0.159, P = 0.383, Fig. 2 . and Fig. 3 .) The median time of FMC to CTA confirmation was 41minutes, while the average time of FMC to CAG was 65.94 ± 3.46 minutes, which is significantly longer than the FMC to CTA confirmation time (p < 0.001). Clinical outcomes and Mortality rate In the end, 15 patients underwent CTA and confirmed the diagnosis of TAAS. Among them, 11 patients make it to the surgery and 4 died before the operation. 2 died peri-operation for the cardiogenic shock, and 9 patients survived, and the 30-day in-hospital mortality was 40%. 17 patients were given antiplatelet therapy and underwent urgent CAG without awareness of the D-dimer results. 5 patients died after CAG confirmation TAAS without making to emergency surgery for deteriorating cardiogenic shock and malignant ventricular arrhythmia. 12 patients underwent emergency surgery, but only 3 patients survived and were discharged. Among the 9 patients, one patient died on the 17th -day post-operation due to massive cerebral infarction, 3 patients died perioperatively because of cardiogenic shock and multiple organ failure. 5 patients died from uncontrollable gastrointestinal bleeding within 2–4 weeks post-surgery. The clinical data and the outcomes of all 32 patients were summarized in Table 4 . The total 30-day in-hospital mortality for the patients with TAAS presenting as STEMI was 62.5% (20/32). The 30-day in-hospital mortality rate for TAAS mimicking STEMI receiving CAG was 82.4% (14/17), the 30-day in-hospital mortality rate for TAAS mimicking STEMI receiving CTA was 40% (6/15) which was significantly lower (P = 0.014). Long-term survival estimates with the use of Kaplan–Meier method after operation for acute type A aortic dissection by diagnostic method. Significant overall difference is observed (P < 0.005 by log-rank test) (Fig. 4 .) Table 4 TAAS diagnostic methods and time consumption Variable CTA (n = 15) CAG (n = 17) P-value TIME (minute) 41[37,47] 65.94 ± 3.46 0.000 Mortality before surgery 4(26.7%) 5(29.4%) 0.897 Cardiac Surgery 11(73.3%) 12(70.6%) 1 Peri-operation mortality 2(18.1%) 9(75%) 0.006 Cause of death Caodiogenic shock 2(100%) 3(33.3% ) 0.695 Cerebral infarction 0(0%) 1(11.1%) 0.155 Gastrointestinal hemorrhage 0(0%) 5(55.6%) 0.000 30-day in hospital mortality 6(40%) 14(82.4%) 0.014 30-day total in hospital mortality 20(62.5%) Data are presented as the median [interquartile range], mean ± standard deviation or no. (%) of patients. TIME, the time from the admission to the ER to the TAAS confirmation. In the CTA diagnosis group, the average survival time was longer than the CAG diagnosis group with fewer patients who had peri-operation complications, especially gastrointestinal bleeding. CTA diagnosis can reduce the 30-day mortality rate by 67.5% (95% CI:0.124–0.850, P = 0.16) The clinical data and the outcomes of all TAAS patients were summarized in Table 4 . Discussion AAS is rare but a nightmare disease of all the emergency rooms. It can affect the aorta and may lead to catastrophic events and associated early mortality rate [ 1 ]. Early diagnosis is very important to improve the survival rate, and early recognition of the condition is crucial. Although the typical patient affected by AAS can be identified by aortic dissection detection risk score plus D-dimer [ 2 ], the patients with atypical features may be misdiagnosed as an uncomplicated regular STEMI [ 3 ]. The incidence of acute coronary syndrome secondary to TAAS ranges from 5.7–11.3% [ 4 – 6 ] due to acute aortic syndrome of the aortic root reaching the coronary ostia. Approximately 2.5% of patients with TAAS present with STEMI [ 6 ] on ECG and misdiagnosis at the emergency department has been shown to be 30–78% [ 7 ] [ 8 ] during the initial assessment. Clearly, any highly suspicious result in physical examination, laboratory test or supplementary examination with a high level of suspicion and awareness is the key to the timely diagnosis and effective therapy for this special group of patients [ 9 ] [ 10 ] before being misdiagnosed as regular STEMI patients and undergoing primary percutaneous coronary intervention. Clinical data including age and sex as well as the history of hypertension (HTN) or family history were not helpful in predicting TAAS since the patients with TAAS in the present study included both male and female with a wide age range, and chest pain and syncope are the most common presenting initial symptoms [ 1 ]. Some patients who had TAAS mimicking regular STEMI share similar risk factors, including hypertension, aging, sex, diabetes mellitus with uncomplicated STEMI patients [ 1 ] [ 11 ] [ 12 ]. As most physicians agree that ECG with elevated ST-segment and chest pain suffice to diagnose regular STEMI [ 13 ] [ 14 ], it was certainly possible that some TAAS might have been ignored because of its extremely low odds since over 99% of STEMI is atherosclerotic in nature [ 13 ]. CTA scanning is of great value to establish the diagnosis[ 10 ]. However, if clinical history and clinical examination may not provide “warning” symptoms, it is very difficult to make the correct and timely differentiate diagnosis, especially in patients with time-sensitive symptoms like cardiogenic shock and malignant ventricular arrhythmia. Emergency CTA is of less value since in primary PCI-capable hospitals, obtaining a CTA imaging could delay the reperfusion therapy. In our study, despite the abnormal result of D-dimer, 53.1% (17/32) patients were misdiagnosed as regular STEMI and more cases of TAAS might be discovered if an autopsy was performed to establish the causes for the mortality among the patients with the diagnosis of STEMI or sudden death. The CAG confirmation time was significantly longer than the CTA confirmation time. While it is painful, we cannot avoid facing these realities: CAG may delay TAAS surgery and antiplatelet therapy may increase the risk of gastrointestinal hemorrhage, as we found in our study. There was some evidence that aortic dissection may lead to end-organ mal-perfusion syndromes [ 15 ] and caused insidious ischemic end-organ complications, which occurred in approximately in one-third of patients [ 16 ]. Studies also found that the patients who underwent CAG who had load dual antiplatelet therapy would have more risk of gastrointestinal hemorrhage [ 1 ]. Our study results were by the abovementioned results, which were TAAS confirmed by CAG had more complications peri-operation like gastrointestinal hemorrhage and leading to a higher mortality rate (82.4%) than the published data (23.4.9–47.7%) from previous studies [ 1 ] [ 11 ]. Since this special group of STEMI patients has a low incidence and no comprehensive large clinical studies, the management for these patients remains challenging and even controversial. The current guidelines have suggested surgical resection and replacement of the thoracic aorta as the gold standard to treat TAAS [ 10 ] [ 17 ] [ 4 ]. On the other hand, prompt coronary revascularization could provide the TAAS patients the critical time for the preparation for the surgical treatment, direct stenting may do good to the unstable patients, but it can also serve as a double-edge sword and lead to severe complications like refractory hemorrhage peri-operation. Of course, the management of STEMI caused by TAAS should be individualized. There is no doubt that stable patients undergo corrective surgery directly, while what may unstabilized patients’ benefit is still not clear. While above all, definitive diagnosis is the most important thing, and up to date, there is no clear guideline to guide the best protocol for distinguishing the diagnosis only the suggestions [ 18 ]. Although D-dimer is of high sensitivity and low specificity, and D-dimer concentration tends to be elevated in many other diseases, such as pulmonary embolism [ 19 ], deep venous thrombosis [ 20 ], cancer [ 21 ], atrial fibrillation [ 22 ], and congestive heart failure [ 23 ]. None of the above diseases are relative contraindications of anti-platelet and reperfusion therapy in STEMI patients, in addition to aortic dissection. As a method to distinguish the STEMI secondary to TAAS and STEMI caused by atherosclerotic disease, it is a very important lab bio-marker that can be obtained within 15minutes in ED before being given antithrombotic therapy and had the advantage of convenience and cheap. Though the probability of STEMI secondary to TAAS occurrence is very low, patients with more pronounced coronary symptoms and hemodynamic instability may benefit from the fast and accurate diagnosis. But the authors point out the extreme infrequency, time-sensitive feature, and high mortality rate of STEMI secondary to TAAS in comparison with the total emergency department visits. The prospective systematic approach is difficult to be tested in a clinical situation. Even in the absence of a firm evidence base, the retrospective-based recommendations that the POCT of D-dimer result is important for differential diagnosis between STEMI and TAAS presenting as STEMI are worth consideration. A major strength of the study was to meet the clinical needs in the management of acute TAAS in the emergency department, to minimize time delay in diagnosis and referral of TAAS and increase awareness of the condition and raise the index of suspicion when managing STEMI. The step may only take a few minutes longer, but it may lead to a slightly earlier precise diagnosis and save more lives. To improve on this rather dismal rate, it is worth a try. Limitations This was a single-center experience for differentiating diagnosis of the STEMI and STEMI secondary to TAAS, and as its retrospective nature, it had its disadvantages. Furthermore, both the sensitivity and specificity of this approach to a real-world emergency department situation are unknown and need to be tested. Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2000, and was approved by the ethics committee for medical research at Shanghai tenth People’s Hospital of Tongji University. The subjects or their legal representatives were fully aware of the nature of the study and agreed to participate and sign the informed consent approved by the ethics committees. Consent for publication Not applicable. Availability of data and materials The data used to support the finding will not be shared publicly. Researchers can contact the corresponding author for detailed information. Competing interests The authors declare that they have no conflict of interest. Sources of Funding None. Authors' contributions All authors made a significant contribution to the work reported, whether that is in the conception, acquisition of data, analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Acknowledgements The authors thank the patients, staff involved in the research for the cooperation. References Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD). Jama. 2000;283:897. Nazerian P, Mueller C, De Matos Soeiro A, Leidel BA, Salvadeo SAT, Giachino F, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes the ADvISED prospective multicenter study. Circulation. 2018;137:250–8. Lovatt S, Wong CW, Schwarz K, Borovac JA, Lo T, Gunning M, et al. Misdiagnosis of aortic dissection: A systematic review of the literature. American Journal of Emergency Medicine. 2022;53:16–22. Kawahito K, Adachi H, Murata SI, Yamaguchi A, Ino T. Coronary Malperfusion Due to Type A Aortic Dissection: Mechanism and Surgical Management. Annals of Thoracic Surgery. 2003;76:1471–6. Pêgo-Fernandes P. Management of aortic dissection that involves the right coronary artery. Cardiovascular Surgery. 1999;7:545–8. Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: Presentation, management, and outcome. Journal of Thoracic and Cardiovascular Surgery. 2001;121:552–60. Zhan S, Hong S, Shan-Shan L, Chen-Ling Y, Lai W, Dong-Wei S, et al. Misdiagnosis of Aortic Dissection: Experience of 361 Patients. Journal of Clinical Hypertension. 2012;14:256–60. Zaschke L, Habazettl H, Thurau J, Matschilles C, Göhlich A, Montagner M, et al. Acute type A aortic dissection: Aortic Dissection Detection Risk Score in emergency care – surgical delay because of initial misdiagnosis. European Heart Journal Acute Cardiovascular Care. 2020;9 3_suppl:S40–7. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. 2018;39:119–77. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: Executive summary: A report of the american college of cardiology foundation/american heart association task force on pra. Circulation. 2010;121:266–369. Howard DPJ, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the oxford vascular study. Circulation. 2013;127:2031–7. Nienaber CA, Clough RE. Management of acute aortic dissection. In: The Lancet. Elsevier; 2015. p. 800–11. Kohn MA, Kwan E, Gupta M, Tabas JA. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. Journal of Emergency Medicine. 2005;29:383–90. Salmasi MY, Hartley P, Hussein M, Jarral O, Pepper J, Nienaber C, et al. Diagnosis and management of acute Type-A aortic dissection in emergency departments: Results of a UK national survey. International Journal of Cardiology. 2020;300:50–9. Czerny M, Schoenhoff F, Etz C, Englberger L, Khaladj N, Zierer A, et al. The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection: Results From the GERAADA Registry. Journal of the American College of Cardiology. 2015;65:2628–35. Bonser RS, Ranasinghe AM, Loubani M, Evans JD, Thalji NMA, Bachet JE, et al. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. Journal of the American College of Cardiology. 2011;58:2455–74. Neri E, Toscano T, Massetti M, Capannini G, Carone E, Tucci E, et al. Operation for acute type A aortic dissection in octogenarians: Is it justified? Journal of Thoracic and Cardiovascular Surgery. 2001;121:259–67. Erbel R, Aboyans V, Boileau C, Bossone E, Di Bartolomeo R, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal. 2014;35:2873–926. Goldhaber SZ, Simons GR, Elliott CG, Haire WD, Toltzis R, Blacklow SC, et al. Quantitative Plasma D-dimer Levels Among Patients Undergoing Pulmonary Angiography for Suspected Pulmonary Embolism. JAMA: The Journal of the American Medical Association. 1993;270:2819–22. Fattorini A, Crippa L, Vigano’ D’Angelo S, Pattarini E, D’Angelo A. Risk of deep vein thrombosis recurrence: High negative predictive value of D-dimer performed during oral anticoagulation. Thrombosis and Haemostasis. 2002;88:162–3. Costantini V, Zacharski LR. Fibrin and cancer. Thrombosis and Haemostasis. 1993;69:406–14. Kumagai K, Fukunami M, Ohmori M, Kitabatake A, Kamada T, Hoki N. Increased intracardiovascular clotting in patients with chronic atrial fibrillation. Journal of the American College of Cardiology. 1990;16:377–80. Jafri SM, Ozawa T, Mammen E, Levine TB, Johnson C, Goldstein S. Platelet function, thrombin and fibrinolytic activity in patients with heart failure. European Heart Journal. 1993;14:205–12. Additional Declarations No competing interests reported. Supplementary Files Table.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 24 Aug, 2022 Reviews received at journal 21 Aug, 2022 Reviews received at journal 12 Jun, 2022 Reviewers agreed at journal 09 Jun, 2022 Reviewers agreed at journal 05 Jun, 2022 Reviewers invited by journal 02 Jun, 2022 Editor assigned by journal 02 Jun, 2022 Editor invited by journal 17 May, 2022 Submission checks completed at journal 17 May, 2022 First submitted to journal 22 Mar, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1479700","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":106614458,"identity":"8f4b5844-f349-453c-b405-16d10e442ed9","order_by":0,"name":"Chang Xiaoxin","email":"","orcid":"","institution":"Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chang","middleName":"","lastName":"Xiaoxin","suffix":""},{"id":106614459,"identity":"4be43ae0-ae52-4f9e-91ec-a9f77ba53b15","order_by":1,"name":"Yao Jianhua","email":"","orcid":"","institution":"Shanghai Tenth People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yao","middleName":"","lastName":"Jianhua","suffix":""},{"id":106614460,"identity":"3084d9c1-ceb1-4d3c-9967-7f617ef86330","order_by":2,"name":"Xu Yawei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYPACCTkIZQAkDhCpxZiHVC0MiT1wJiEtBjdyDD/zVFik72fvPfzCooBBju9GAuPnAjxaJGfkGEvznJHI7eE5l2YBdJix5I0EZukZeLTwS+QYSOe2AbVI5JgZALUkbriRwMbMg0cLm0SO8e/cfxLpPFAt9QS1AG0xk85tkEgAajF+ANSSYEBIi2TPszLrP8ckDHvOnDEDBrKE4cwzD5ul8WkxOJ68+eaMmjp59vYe488Sf2zk+Y4nH/yMTwsDA4cB3F/SEgwSQJqxAa8GBgb2BzAW88cPBNSOglEwCkbByAQAQJFC1sNruGkAAAAASUVORK5CYII=","orcid":"","institution":"Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Yawei","suffix":""}],"badges":[],"createdAt":"2022-03-23 02:14:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1479700/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1479700/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":21677469,"identity":"4ac41cf5-26ff-4b9d-8fb8-b4ff174e9c4b","added_by":"auto","created_at":"2022-05-19 17:37:04","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":208853,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver-operating characteristic curves. The arrow indicates the point where the cutoff value for D-dimer is set at 2.155ug/mL had the best sensitivity of 100% and specificity of 96.9%.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1479700/v1/79311278cb473f119d78dbbe.jpeg"},{"id":21677967,"identity":"04f2dcd8-d347-47bf-a4a0-63e31bdc521d","added_by":"auto","created_at":"2022-05-19 17:42:04","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":62964,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between D-dimer concentration and TIME (time from the onset of symptoms to first medical contact) in the TAAS group.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1479700/v1/780a6843db8b5984ccf64a54.jpeg"},{"id":21677471,"identity":"854bdeb1-4a9a-48de-b1d1-989a11113c5b","added_by":"auto","created_at":"2022-05-19 17:37:04","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16699,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between D-dimer concentration and TIME (time from the onset of symptoms to first medical contact) in the STEMI group.\u003c/p\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1479700/v1/a26e9eb22b11fa3f78fa5b6b.jpeg"},{"id":21677468,"identity":"ad0a4f82-921e-4895-8616-9e21a090e861","added_by":"auto","created_at":"2022-05-19 17:37:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":90890,"visible":true,"origin":"","legend":"\u003cp\u003eLong-term survival estimates with the use of Kaplan–Meier method after operation for acute type A aortic dissection by diagnostic method. Significant overall difference is observed (P \u0026lt;0.005 by log-rank test)\u003c/p\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-1479700/v1/b9f798d69da9e83183956a88.png"},{"id":21677968,"identity":"466c9ff3-58ce-40db-a442-126693f34e2d","added_by":"auto","created_at":"2022-05-19 17:42:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":491018,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1479700/v1/38ab16d5-55bb-4e92-bed8-dc5d27cf26b9.pdf"},{"id":21677467,"identity":"a031ea60-0770-434a-aa4d-85b65faf0e8c","added_by":"auto","created_at":"2022-05-19 17:37:04","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27381,"visible":true,"origin":"","legend":"","description":"","filename":"Table.docx","url":"https://assets-eu.researchsquare.com/files/rs-1479700/v1/4eac08b533d94e6bb8eb6b59.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStanford type A aortic syndrome (TAAS) extends to the ostium of the coronary artery may lead to acute coronary occlusion, thus leading to acute coronary syndrome (ACS) and mimicking as STEMI in electrocardiography examination. It is a life-threatening acute vascular disease that is not easily detectable because the primary electrocardiographic (ECG) presentation will make physicians ignore the atypical clinical manifestations and lead to misdiagnosis in the Emergency department (ED). Methods include computed tomography (CT), transesophageal echocardiography (TEE), transthoracic echocardiography (TTE), magnetic resonance imaging (MRI), and point-of-care ultrasound (POCUS) are used to exclude the TAAS in STEMI patients in clinical practice when there is a suspicion. While in ED, TAAS might be ignored and misdiagnosed because definitive imaging may delay the reperfusion time and regular STEMI happens more often. Therefore, it is crucial to find a reliable, fast method to differentiate whether the STEMI is secondary to TAAS and to reduce misdiagnosis. Previous studies have found that D-dimer concentrations can be elevated in TAAS and many other diseases, despite its low specificity for the condition, we found that POCT of D-dimer is a simple and efficient method for detecting and discriminating acute aortic syndrome with ST-elevated myocardial infarction in the ED and thus leading to the important clinical decision making.\u003c/p\u003e \u003cp\u003eHere, we retrospectively analyzed the clinical characteristics, lab tests, and outcomes of the confirmed patients diagnosed with STEMI and STEMI secondary to TAAS, hoping this study could provide deep insight into such conditions and offered an effective and fast method to reduce such misdiagnosis and improve the prognosis of these patients.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis is a one-center retrospective study. 34 patients who confirmed STEMI secondary to TAAS and 551 STEMI patients in ED enrolled in the study between January 1st, 2017 and October 1st 2021 were evaluated. 24 STEMI patients and 2 TAAS patients were excluded from the study for the lack of the POCT of D-dimer or cardiac infarct biomarker results in the ED.\u003c/p\u003e \u003cp\u003eStanford type A aortic syndrome was defined as intramural hematoma or aortic dissection involvement of the ascending aorta and aortic arch. Enhanced computed tomography (CTA) or coronary angiography (CAG) confirmed the diagnosis of TAAS.\u003c/p\u003e \u003cp\u003eThe diagnosis of STEMI was based on the latest criteria established by the American College of Cardiology and European Society of Cardiology, including: (1) chest pain lasting for over 30 min, (2) at least two contiguous leads with ST-segment elevation 2.5 mm in men\u0026thinsp;\u0026lt;\u0026thinsp;40 years, 2mm in men over 40 years, or 1.5 mm in women in leads V2\u0026ndash;V3 and/or1mm in the other leads, (3) an increase of cardiac biomarker values with at least one value above the 99th percentile of the upper reference limit. And other ECG signs of coronary artery occlusion like De winter syndrome were also included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e After approval by the Clinical Ethics Committee (CEC) of the Shanghai Tenth People\u0026rsquo;s Hospital, two independent physicians retrospectively collected and reviewed the general clinical information, demographics, treatment records, and essential time points according to standards. POCT results, including cTNI, myoglobin (Myo), creatine kinase\u0026ndash;myocardial band (CK-MB), brain natriuretic peptide (BNP), D-dimer (DD) were recorded. POCT results were available within 15 minutes with the TRIAGE platform assay panels (Alere, San Diego, CA, USA). The following assay results were predefined to be positive on either blood draw: troponin I 0\u0026middot;05 ng/mL or greater, CK-MB 4\u0026middot;3 ng/mL or greater, Myo concentration of 108 ng/mL or greater, BNP 100pg/mL or greater, and D-dimer 600ng/mL or greater. The point cutoffs were based on manufacturer recommendations, with an elevated result defined as any detectable concentration of results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe frequency and percentage of the categorical data were determined. Continuous variables were presented as the 25% and 75% percentiles, median, mean and standard deviation (SD), depending on whether the data were normally distributed. A Mann-Whitney U test, chi-square, the Fischer exact or t-test were used to analyze the difference. A value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered being significant. Propensity score matching (PSM) was used for calculating variables included sex, age, hypertension, coronary heart disease, smoking, diabetes mellitus, Marfan syndrome, previous percutaneous coronary intervention (PCI), previous coronary artery disease, previous myocardial infarction, known aneurysm, and hyperlipidemia to balance heterogeneity in demographics. The 1:1 PSM was applied to create the matched TAAS group and STEMI group with a caliper distance of 0.1. After PSM, the differences between the two groups were compared again using the aforementioned statistical methods.\u003c/p\u003e \u003cp\u003eReceiver operating characteristic (ROC) curves were constructed after calculation of the sensitivity for the matched TAAS group to determine the best cutoff value with a 95% confidence interval (CI). The Kaplan-Meier estimates of the mortality rates in both groups are reported along with the corresponding hazard ratios (HR) and 95% CIs. All statistical analyses were performed using SPSS Statistics, version 26 (Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eBaseline Characteristics\u003c/h2\u003e\n\u003cp\u003eDetailed demographics are displayed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. 527 STEMI patients and 32 TAAS patients were finally enrolled in the study from January 1st, 2016 to October 1st, 2021. Male patients accounted mainly in both TAAS and STEMI groups (78.1% vs. 82.0%, P\u0026thinsp;=\u0026thinsp;0.584). Compared with the STEMI group, TAAS group had similar age (64[59\u0026ndash;66] years vs. 66[61\u0026ndash;73] years, P\u0026thinsp;=\u0026thinsp;0.130), similar proportions of smokers (90.6% vs. 90.5%, P\u0026thinsp;=\u0026thinsp;0.983), of patients with previous history of PCI (12.5% vs. 13.3%, P\u0026thinsp;=\u0026thinsp;0.899), of patients with hyperlipidemia (56.3% vs. 53.7%, P\u0026thinsp;=\u0026thinsp;0.779), of patients with hypertension (87.5% vs. 90.7%, P\u0026thinsp;=\u0026thinsp;0.548), and of patients with coronary heart disease (25.0% vs. 26.6%, P\u0026thinsp;=\u0026thinsp;0.845), but of more patients with known aortic aneurysm (9.4% vs. 2.8%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) based on the medical history. After 1:1 PSM analysis, each of 32 patients in the TAAS-group and the STEMI-group was extracted, and baseline characteristics were well balanced between the two groups.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographics and characteristics of the patients\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePre-PSM\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePost-PSM\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTAAS group\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSTEMI group\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;527)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP- value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTAAS group\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSTEMI group\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64[59,66]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66[61,73]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.130\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64[59,66]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69[59.5,75.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.053\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMen\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25(78.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e432(82.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.584\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25(78.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.756\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of tobacco (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29(90.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e477(90.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.983\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29(90.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29(90.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7(21.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e154(29.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.719\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13(40.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9(28.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.292\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferred from subordinate hospitals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(18.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e108(20.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.812\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(18.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(18.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFirst consultation at our hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e445(79.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.812\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eRisk factors and characteristics (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of hypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28(87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e478(90.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.548\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28(87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28(87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarfan syndrome\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKnown aortic aneurysm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15(2.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.042\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.302\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrevious history of PCI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70(13.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.899\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(12.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrevious atherosclerostic coronary artery disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8(25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e140(26.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.845\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9(28.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8(25%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.777\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeripheral artery disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25(4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrevious myocardio infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12(2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.814\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRenal dysfunction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32(5.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.492\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.554\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHyperlipidemia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18(56.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e283(53.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.779\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18(56.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18(56.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCold sweats\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e406(77%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.581\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26(81.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eData are presented as the median [interquartile range] or no. (%) of patients.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eClinical Data\u003c/h2\u003e\n\u003cp\u003eThe clinical characteristics of these patients were also summarized in Table\u0026nbsp;2. Anterior chest pain was the most common initial presenting symptom among the TAAS and STEMI groups (28.1% vs. 30.2%, P\u0026thinsp;=\u0026thinsp;0.226), subsequent by syncope (25.0% vs. 19.4%, P\u0026thinsp;=\u0026thinsp;0.435) in PSM analysis. In the TAAS group, 7 (21.9%) patients also suffered from abdominal as well as anterior chest pain, 4 (12.5%) were sent to the hospital for cardiogenic shock and 1 (3.1%) had no other symptoms except abdominal pain. Differences in initial symptoms\u0026rsquo; presentations were not significant between the 2 groups, and patients in both groups had normal blood pressure (105mmHg vs. 105mmHg, P\u0026thinsp;=\u0026thinsp;0.543). Even patients in the STEMI group had more heartbeats (78 bpm vs. 60 bpm, P\u0026thinsp;=\u0026thinsp;0.011) per minute, the result was of no clinical specificity.\u003c/p\u003e\n\u003cp\u003eTable 2. Clinical symptoms and ECG presentations\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"173\"\u003e\n\u003cp\u003ePre-PSM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"180\"\u003e\n\u003cp\u003ePost-PSM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003eTAAS group\u003c/p\u003e\n\u003cp\u003e(n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003eSTEMI group\u003c/p\u003e\n\u003cp\u003e(n=527)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003eP- value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003eTAAS group\u003c/p\u003e\n\u003cp\u003e(n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eSTEMI group\u003c/p\u003e\n\u003cp\u003e(n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\" width=\"568\"\u003e\n\u003cp\u003eClinical symptoms\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eAbdinal pain + syncope\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e11(2.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eAnterior chest pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e9(28.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e159(30.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.806\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e9(28.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e5(15.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.226\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003ePosterior chest pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e11(2.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.409\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eBack pain + syncope\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e5(0.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eabdomina pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e29(5.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.865\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.606\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eChest pain + back pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e9(1.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eCardiogenic shock\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e4(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e45(8.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.442\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e4(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eChest pain + syncope\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2(6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e24(4.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.992\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e2(6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eSyncope\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e8(25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e102(19.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.435\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e8(25%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e9(28.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.777\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003ePersistent or intermittent chest tightness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e30(5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.325\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e4(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.113\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eAnterior pain + abdmina pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e7(21.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e98(18.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.645\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e7(21.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.302\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"422\"\u003e\n\u003cp\u003eDifferent presentations of ST-segments elevation in ECG\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eII, III, AVF leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e20(62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e201(38.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e20(62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e13(40.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.08\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eV1-V3 leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2(6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e45(8.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.651\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e2(6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3(9.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eV1-V5 leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e5(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e31(5.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.261\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e4(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.352\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eV3-V5 leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e190(36.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e13(40.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eV7-V9 leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e4(0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e2(6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.492\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eV3R-V4R leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e7(1.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eAVR lead\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e16(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eI, AVL leads\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e25(4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.388\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eDe Winter Syndrome\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e7(1.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.949\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e1(3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eNew onset LBBB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e1(0.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"422\"\u003e\n\u003cp\u003ePhysical examination\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eSystolic pressure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e105[100,124]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e105[100,120]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.415\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e105[100,124]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e105[95,122]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.543\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eDiastolic pressure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e60[55,65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e60[55,65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.676\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e60[55,65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e57[54,65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.566\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eHeart rate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e60[51.5,85]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e78[75,84]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e60[51.5,85]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e78[71,83]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.011\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003eRespiration rate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e22[20,23.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e22[18,23]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e0.042\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e22[20,23.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e22[18,23]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e0.237\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as the median [interquartile range] or no. (%) of patients.\u003c/p\u003e\n\u003cp\u003eThe median time of symptom onset to first medical contact was 85 minutes and 180 minutes and the median first medical contact time to ECG examination time was 2 minutes and 3 minutes in the TAAS group and STEMI group, respectively.\u003c/p\u003e\n\u003cp\u003eAmong the 32 patients in the TAAS group, 20 patients had ST-segments elevation in II, III, AVF leads, and 4 patients combined with level III atrioventricular block. While it made no difference in most types of elevation in the ECG except more patients in the STEMI group could have the V3-V5 leads ST-segments elevation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eLaboratory test and POCT results\u003c/h2\u003e\n\u003cp\u003eAll patients enrolled had point-of-care testing. The median time of reports releasing time was 17 minutes in the TAAS group and 26 minutes STEMI group post PSM analysis. In PSM analysis, patients in the STEMI group had higher positive cTNI (0.174ng/mL vs. 0.055 ng/mL, P\u0026thinsp;=\u0026thinsp;0.008) results than the TAAS group, but CK-MB (9.35ng/mL vs. 5.02ng/mL, P\u0026thinsp;=\u0026thinsp;0.151) and Myo (106.00ng/mL vs. 57.16ng/mL, P\u0026thinsp;=\u0026thinsp;0.055) made no significant differences between the 2 groups. While patients in the TAAS group had extremely higher D-dimer (31.500ug/mL vs. 0.365ug/mL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and LDH (527.5U/L vs.350.0U/L, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) results than the STEMI group. The concentrations of leukocyte count (WBC), platelet (PLT), hemoglobin (Hb), hs-CRP (CRP), and serum creatinine were not significantly different between the two groups (Table\u0026nbsp;3.).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3. TIMEs and lab tests in ED\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"227\"\u003e\n\u003cp\u003ePre- PSM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"240\"\u003e\n\u003cp\u003ePost-PSM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003evariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003eTAAS group\u003c/p\u003e\n\u003cp\u003e(n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003eSTEMI group (n=527)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003eTAAS group (n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eSTEMI group\u003c/p\u003e\n\u003cp\u003e(n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"496\"\u003e\n\u003cp\u003eTime description (minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eTime from symptoms onset to admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e85[55,175]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e180[120,250]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e85[55,175]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e180[120,300]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eTime from admission to ECG\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e2[1,3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e3[2,5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e2[1,3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e3[2,5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eTime from admission to D-dimer result\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e17[15,26.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e26[22,27]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e17[15,26.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e26[21,27]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"496\"\u003e\n\u003cp\u003eLab test results\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eMyoglobin (ng/mL)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e296.45\u0026plusmn;592.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e439.57 \u0026plusmn;560.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e57.16[25.5,306]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e106.5[56.08,481.25]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.055\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eCK-MB (ng/mL)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e5.02[3.11,7.49]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e10.61[3.31,63.93]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.012\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e5.02[3.11,7.49]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e9.35[3.15,54.65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.151\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eLDH (U/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e527.5[415.5,727]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e566[393,984]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.602\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e527.5[415.5,727]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e350[240,524.50]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.007\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eD-dimer (ug/mL)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e31.5[4.77,50.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e0.44[0.26,0.83]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e31.5[4.77,50.55]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0.365[0.23,0.715]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003ecTNI (ng/mL)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e0.055[0.008,0.109]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e0.177[0.455,0.87]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e0.055[0.008,0.109]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0.174[0.026,0.875]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.008\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eWBC (\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e12.00[9.06,14.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e10.48[8.09,13.46]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.188\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e12.00[9.06,14.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e11.6[8.53,14.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.941\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003ePLT (\u0026times;109/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e256[219.5,293.0]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e225[180,278]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e256[219.5,293]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e251[211.5,292]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.726\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eHemoglobin(g/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e142.5[129.0,158.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e140[129,158]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.668\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e142.5[129,158]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e140[128.5,158.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.814\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eHs-CRP (mg/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e3.39[1.56,15.73]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e5.55[1.92,12.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.682\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e3.39[1.56,15.73]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e3.71[1.81,20.63]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.682\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"109\"\u003e\n\u003cp\u003eSerum creatinine (umol/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e89[67.00,106.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e71[56.8,88]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e89[67,106]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e72.9[56.45,106.8]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.394\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as the median [interquartile range], mean \u0026plusmn; standard deviation or no. (%) of patients.\u003c/p\u003e\n\u003cp\u003eThe sensitivities for the TAAS of each cutoff value were calculated and used to construct the ROC curves (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The AUC values were 0.998 (95% CI:0.993-1.000) for the D-dimer, 0.695 (95% CI: 0.562\u0026ndash;0.828) for the LDH, 0.308 (95% CI: 0.176\u0026ndash;0.439) for the cTNT, 0.396 (95% CI: 0.252\u0026ndash;0.539) for the CK-MB, 0.360 (95% CI:0.223\u0026ndash;0.498) for the Myo,0.470 (95% CI:0.328\u0026ndash;0.612) for the hs-CRP, 0.505 (95% CI:0.363\u0026ndash;0.648) for the WBC.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnd the D-dimer cutoff value of 2.155ug/mL had the best sensitivity of 100% and 96.9% of specificity. No significant correlation between the -D-dimer concentration and the time from symptom onset to first medical contact in both groups (TAAS group: r=-0.248, P\u0026thinsp;=\u0026thinsp;0.170; STEMI group: r=-0.159, P\u0026thinsp;=\u0026thinsp;0.383, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. and Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe median time of FMC to CTA confirmation was 41minutes, while the average time of FMC to CAG was 65.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46 minutes, which is significantly longer than the FMC to CTA confirmation time (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eClinical outcomes and Mortality rate\u003c/h2\u003e\n\u003cp\u003eIn the end, 15 patients underwent CTA and confirmed the diagnosis of TAAS. Among them, 11 patients make it to the surgery and 4 died before the operation. 2 died peri-operation for the cardiogenic shock, and 9 patients survived, and the 30-day in-hospital mortality was 40%. 17 patients were given antiplatelet therapy and underwent urgent CAG without awareness of the D-dimer results. 5 patients died after CAG confirmation TAAS without making to emergency surgery for deteriorating cardiogenic shock and malignant ventricular arrhythmia. 12 patients underwent emergency surgery, but only 3 patients survived and were discharged. Among the 9 patients, one patient died on the 17th -day post-operation due to massive cerebral infarction, 3 patients died perioperatively because of cardiogenic shock and multiple organ failure. 5 patients died from uncontrollable gastrointestinal bleeding within 2\u0026ndash;4 weeks post-surgery. The clinical data and the outcomes of all 32 patients were summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. The total 30-day in-hospital mortality for the patients with TAAS presenting as STEMI was 62.5% (20/32). The 30-day in-hospital mortality rate for TAAS mimicking STEMI receiving CAG was 82.4% (14/17), the 30-day in-hospital mortality rate for TAAS mimicking STEMI receiving CTA was 40% (6/15) which was significantly lower (P\u0026thinsp;=\u0026thinsp;0.014). Long-term survival estimates with the use of Kaplan\u0026ndash;Meier method after operation for acute type A aortic dissection by diagnostic method. Significant overall difference is observed (P\u0026thinsp;\u0026lt;\u0026thinsp;0.005 by log-rank test) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTAAS diagnostic methods and time consumption\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCTA (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCAG (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTIME (minute)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41[37,47]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMortality before surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(26.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(29.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.897\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCardiac Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11(73.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12(70.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeri-operation mortality\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(18.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9(75%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCause of death\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCaodiogenic shock\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(33.3%\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.695\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCerebral infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.155\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGastrointestinal hemorrhage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(55.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30-day in hospital mortality\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(40%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14(82.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30-day total in hospital mortality\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e20(62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eData are presented as the median [interquartile range], mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or no. (%) of patients.\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eTIME, the time from the admission to the ER to the TAAS confirmation.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the CTA diagnosis group, the average survival time was longer than the CAG diagnosis group with fewer patients who had peri-operation complications, especially gastrointestinal bleeding. CTA diagnosis can reduce the 30-day mortality rate by 67.5% (95% CI:0.124\u0026ndash;0.850, P\u0026thinsp;=\u0026thinsp;0.16) The clinical data and the outcomes of all TAAS patients were summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAAS is rare but a nightmare disease of all the emergency rooms. It can affect the aorta and may lead to catastrophic events and associated early mortality rate [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Early diagnosis is very important to improve the survival rate, and early recognition of the condition is crucial. Although the typical patient affected by AAS can be identified by aortic dissection detection risk score plus D-dimer [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], the patients with atypical features may be misdiagnosed as an uncomplicated regular STEMI [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The incidence of acute coronary syndrome secondary to TAAS ranges from 5.7\u0026ndash;11.3% [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] due to acute aortic syndrome of the aortic root reaching the coronary ostia. Approximately 2.5% of patients with TAAS present with STEMI [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] on ECG and misdiagnosis at the emergency department has been shown to be 30\u0026ndash;78% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] during the initial assessment.\u003c/p\u003e \u003cp\u003eClearly, any highly suspicious result in physical examination, laboratory test or supplementary examination with a high level of suspicion and awareness is the key to the timely diagnosis and effective therapy for this special group of patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] before being misdiagnosed as regular STEMI patients and undergoing primary percutaneous coronary intervention. Clinical data including age and sex as well as the history of hypertension (HTN) or family history were not helpful in predicting TAAS since the patients with TAAS in the present study included both male and female with a wide age range, and chest pain and syncope are the most common presenting initial symptoms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Some patients who had TAAS mimicking regular STEMI share similar risk factors, including hypertension, aging, sex, diabetes mellitus with uncomplicated STEMI patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As most physicians agree that ECG with elevated ST-segment and chest pain suffice to diagnose regular STEMI [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], it was certainly possible that some TAAS might have been ignored because of its extremely low odds since over 99% of STEMI is atherosclerotic in nature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCTA scanning is of great value to establish the diagnosis[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, if clinical history and clinical examination may not provide \u0026ldquo;warning\u0026rdquo; symptoms, it is very difficult to make the correct and timely differentiate diagnosis, especially in patients with time-sensitive symptoms like cardiogenic shock and malignant ventricular arrhythmia. Emergency CTA is of less value since in primary PCI-capable hospitals, obtaining a CTA imaging could delay the reperfusion therapy.\u003c/p\u003e \u003cp\u003eIn our study, despite the abnormal result of D-dimer, 53.1% (17/32) patients were misdiagnosed as regular STEMI and more cases of TAAS might be discovered if an autopsy was performed to establish the causes for the mortality among the patients with the diagnosis of STEMI or sudden death. The CAG confirmation time was significantly longer than the CTA confirmation time. While it is painful, we cannot avoid facing these realities: CAG may delay TAAS surgery and antiplatelet therapy may increase the risk of gastrointestinal hemorrhage, as we found in our study.\u003c/p\u003e \u003cp\u003eThere was some evidence that aortic dissection may lead to end-organ mal-perfusion syndromes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and caused insidious ischemic end-organ complications, which occurred in approximately in one-third of patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Studies also found that the patients who underwent CAG who had load dual antiplatelet therapy would have more risk of gastrointestinal hemorrhage [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Our study results were by the abovementioned results, which were TAAS confirmed by CAG had more complications peri-operation like gastrointestinal hemorrhage and leading to a higher mortality rate (82.4%) than the published data (23.4.9\u0026ndash;47.7%) from previous studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince this special group of STEMI patients has a low incidence and no comprehensive large clinical studies, the management for these patients remains challenging and even controversial. The current guidelines have suggested surgical resection and replacement of the thoracic aorta as the gold standard to treat TAAS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. On the other hand, prompt coronary revascularization could provide the TAAS patients the critical time for the preparation for the surgical treatment, direct stenting may do good to the unstable patients, but it can also serve as a double-edge sword and lead to severe complications like refractory hemorrhage peri-operation. Of course, the management of STEMI caused by TAAS should be individualized. There is no doubt that stable patients undergo corrective surgery directly, while what may unstabilized patients\u0026rsquo; benefit is still not clear. While above all, definitive diagnosis is the most important thing, and up to date, there is no clear guideline to guide the best protocol for distinguishing the diagnosis only the suggestions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough D-dimer is of high sensitivity and low specificity, and D-dimer concentration tends to be elevated in many other diseases, such as pulmonary embolism [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], deep venous thrombosis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], cancer [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], atrial fibrillation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and congestive heart failure [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. None of the above diseases are relative contraindications of anti-platelet and reperfusion therapy in STEMI patients, in addition to aortic dissection. As a method to distinguish the STEMI secondary to TAAS and STEMI caused by atherosclerotic disease, it is a very important lab bio-marker that can be obtained within 15minutes in ED before being given antithrombotic therapy and had the advantage of convenience and cheap. Though the probability of STEMI secondary to TAAS occurrence is very low, patients with more pronounced coronary symptoms and hemodynamic instability may benefit from the fast and accurate diagnosis.\u003c/p\u003e \u003cp\u003eBut the authors point out the extreme infrequency, time-sensitive feature, and high mortality rate of STEMI secondary to TAAS in comparison with the total emergency department visits. The prospective systematic approach is difficult to be tested in a clinical situation. Even in the absence of a firm evidence base, the retrospective-based recommendations that the POCT of D-dimer result is important for differential diagnosis between STEMI and TAAS presenting as STEMI are worth consideration. A major strength of the study was to meet the clinical needs in the management of acute TAAS in the emergency department, to minimize time delay in diagnosis and referral of TAAS and increase awareness of the condition and raise the index of suspicion when managing STEMI. The step may only take a few minutes longer, but it may lead to a slightly earlier precise diagnosis and save more lives. To improve on this rather dismal rate, it is worth a try.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis was a single-center experience for differentiating diagnosis of the STEMI and STEMI secondary to TAAS, and as its retrospective nature, it had its disadvantages. Furthermore, both the sensitivity and specificity of this approach to a real-world emergency department situation are unknown and need to be tested.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2000, and was approved by the ethics committee for medical research at Shanghai tenth People\u0026rsquo;s Hospital of Tongji University. The subjects or their legal representatives were fully aware of the nature of the study and agreed to participate and sign the informed consent approved by the ethics committees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the finding will not be shared publicly. Researchers can contact the corresponding author for detailed information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made a significant contribution to the work reported, whether that is in the conception, acquisition of data, analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patients, staff involved in the research for the cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. 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Operation for acute type A aortic dissection in octogenarians: Is it justified? Journal of Thoracic and Cardiovascular Surgery. 2001;121:259\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErbel R, Aboyans V, Boileau C, Bossone E, Di Bartolomeo R, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal. 2014;35:2873\u0026ndash;926.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldhaber SZ, Simons GR, Elliott CG, Haire WD, Toltzis R, Blacklow SC, et al. Quantitative Plasma D-dimer Levels Among Patients Undergoing Pulmonary Angiography for Suspected Pulmonary Embolism. JAMA: The Journal of the American Medical Association. 1993;270:2819\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFattorini A, Crippa L, Vigano\u0026rsquo; D\u0026rsquo;Angelo S, Pattarini E, D\u0026rsquo;Angelo A. Risk of deep vein thrombosis recurrence: High negative predictive value of D-dimer performed during oral anticoagulation. Thrombosis and Haemostasis. 2002;88:162\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCostantini V, Zacharski LR. Fibrin and cancer. Thrombosis and Haemostasis. 1993;69:406\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumagai K, Fukunami M, Ohmori M, Kitabatake A, Kamada T, Hoki N. Increased intracardiovascular clotting in patients with chronic atrial fibrillation. Journal of the American College of Cardiology. 1990;16:377\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJafri SM, Ozawa T, Mammen E, Levine TB, Johnson C, Goldstein S. Platelet function, thrombin and fibrinolytic activity in patients with heart failure. European Heart Journal. 1993;14:205\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Stanford type A aortic syndrome, Coronary reperfusion therapy, D-dimer, ST-segment elevated myocardial infarction.","lastPublishedDoi":"10.21203/rs.3.rs-1479700/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1479700/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe research of the sensitivity and specificity point-of-care testing (POCT) of D-dimer as a diagnostic protocol for differential diagnosis of TAAS (hereafter as TAAS) mimicking ST-elevated myocardial infarction (STEMI) with regular STEMI in the emergency department is limited.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Full medical information of 32 patients confirmed TAAS and 527 patients confirmed STEMI from January 1\u003csup\u003est\u003c/sup\u003e, 2016 to October 1\u003csup\u003est\u003c/sup\u003e, 2021 were retrospectively analyzed in Shanghai tenth People’s Hospital of Tongji University.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The baseline characteristics of two groups of patients were well-balanced post propensity score matching (PSM) analysis, and each group had 32 patients enrolled. Patients in the STEMI group had higher positive cardiac troponin I (cTNI) (0.174ng/mL vs. 0.055ng/mL, P=0.008) results but lower D-dimer (0.365ug/mL vs. 31.50ug/mL, P\u0026lt;0.001) results than the TAAS group. The AUC values were 0.998 (95% CI:0.993-1.000) for the D-dimer, and the D-dimer cutoff value of 2.155ug/mL had the best sensitivity of 100% and specificity of 96.9% in the TAAS group. No significant correlation between the D-dimer concentration and the time from symptom onset to first medical contact in both groups (TAAS group: r=-0.248, P=0.170; STEMI group: r=-0.159, P=0.383). The total in-hospital mortality for the patients with TAAS presenting as STEMI was 62.5% (20/32). The mortality rate for TAAS patients confirmed by CTA was significantly lower (40% vs. 82.4%, P=0.014) than the mortality rate for TAAS patients confirmed by CAG and had a longer average survival time (log-rank=0.015) but less peri-surgical complications, especially gastrointestinal hemorrhage (0.00% vs. 55.6%, P\u0026lt;0.001). CTA diagnosis can reduce the mortality rate by 67.5% (95%CI:0.124-0.850, P=0.16).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe POCT D-dimer can exclude TAAS mimicking STEMI from regular STEMI prior to reperfusion therapy.\u003c/p\u003e","manuscriptTitle":"The point-of-care D-dimer test provides a fast and accurate differential diagnosis of Stanford Type A aortic syndrome and ST-elevated myocardial infarction in emergencies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-19 17:37:02","doi":"10.21203/rs.3.rs-1479700/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-24T05:58:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-21T06:25:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-06-12T06:24:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e1e23f3f-57ee-4ac4-acb8-8b7f1f1afe96","date":"2022-06-09T06:34:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ba028e6f-7240-46b3-afb8-0eed1ceded5f","date":"2022-06-05T21:48:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-02T17:41:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-06-02T17:21:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-17T09:03:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-17T09:00:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2022-03-23T02:12:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d7896e9-8aef-4c85-9903-6c6c5a81c805","owner":[],"postedDate":"May 19th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-29T09:14:18+00:00","versionOfRecord":[],"versionCreatedAt":"2022-05-19 17:37:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1479700","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1479700","identity":"rs-1479700","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}