Canadians have died suddenly from a torn aorta missed after ER visit. Here's what you need to know
For emergency doctors, the fear of missing a potentially lethal diagnosis “fluctuates between healthy and practice-altering paranoia,” Calgary emergency doctors Eddy Lang and Niklas Bobrovitz recently wrote.
Aortic dissection — a tear in the body’s main artery — would qualify for the latter. Death can happen fast.
A new study documenting 43 cases of delayed or missed diagnoses of aortic dissection in Canadian emergency departments over a 10-year span that resulted in medical-legal action is highlighting how such a catastrophic medical emergency can be missed.
Thirty-six people died of their aortic dissection. Thirty were only diagnosed after their death. Forty per cent of missed dissection deaths occurred after the person was sent home from emergency — “perhaps the most feared outcome for patients and providers alike,” Lang and Bobrovitz wrote in an accompanying editorial in the Canadian Journal of Emergency Medicine.
Aortic dissection is a vascular emergency “with a fairly high mortality rate,” Bobrovitz, an emergency medicine resident at the University of Calgary and health services researcher, said in an interview with National Post.
“If you think about your heart, the main vessel that comes off your heart that feeds blood to all your organs and tissues is called your aorta. It kind of curves up towards the head in your upper chest and then goes down into your abdomen — your abdominal aorta.” From there it descends into the pelvis, branching off “into a bunch of different vessels.”
The wall of the aorta is composed of multiple layers. Aorta dissection happens when there’s a tear on the inner wall. “When blood gets diverted through that tear in the inner wall, and the inner wall separates from the outer wall, you can get decreased flow to your vital organs,” Bobrovitz said, including reduced blood flow to the heart, brain and lungs, causing serious organ damage and death.
“It can happen fast, depending on where the tear is,” he said. The closer it is to the heart, the higher the risk of blocking flow to the coronary vessels. “You’d have a heart attack very, very quickly, like within seconds to minutes, and potentially die.”
A tear can lead to a full aortic rupture from the pressure from the pooled, leaking blood. Canadian actor Alan Thicke died in 2016, age 69, from a ruptured aorta three hours after experiencing an aortic dissection. Thicke collapsed while playing ice hockey with his son.
In 2003, American actor John Ritter died suddenly from a misdiagnosed thoracic aortic dissection.
Aortic dissection is considered the “great imitator” because symptoms can mimic other conditions. Not everyone experiences textbook symptoms like sudden severe tearing or ripping pain in the chest, back or abdomen.
“It’s very similar to a kidney stone: people can’t get comfortable,” Bobrovitz said. “They have constant pain. No position feels good. It doesn’t change when they sit up, or when they lie down. They can be sweaty.”
Chest pain is the most common complaint seen in an emergency department — it can be tricky to tease out what’s serious and what isn’t. As well, “a surprising number of diagnostic tests are normal, even if you have a dissection,” Bobrovitz said.
Risks include untreated high blood pressure, connective tissue diseases like Marfan syndrome that put people at higher risk of tears, people who’ve undergone recent heart valve surgery or those with heart abnormalities.
It’s relatively rare. Of 3,531 medico-legal cases involving an emergency department that closed between January 2014 through to the end of December 2023, just 43 were related to aortic dissection. “It’s not a super common diagnosis,” Bobrovitz said. An ED doctor might see one aortic dissection a year. However, the new study is important, he said, “because the mortality rate is very high, and they are missed in emergency.” Without treatment, like surgery to repair the damaged artery, the death rate approaches 50 per cent within the first 48 hours after symptoms start.
The new study assessing the “diagnostic pitfalls” that lead to missed dissections is based on an analysis of cases handled by the Canadian Medical Protective Association, the powerful body that provides legal support to doctors facing a civil lawsuit or complaints to their licensing college.
“Recurring themes” included inadequate physical exams, failing to perform a test to rule out a dissection, “anchoring” or locking on symptoms that seem like harmless indigestion or muscle pain, misinterpreted chest X-rays, overcrowded emergency rooms, no radiologists available overnight, no hospital willing to accept a transfer for urgent heart surgery and other, often system-level, failures.
With the worst tears, the highest risk of death is in the first few hours. “Deterioration and death in these patients can occur rapidly, even in patients who appear initially stable,” the research team wrote.
One Ontario study found that the dissection “miss rate” is 12.5 per cent, “far above the less than one per cent rate most Canadian physicians would tolerate,” Lang and Bobrovitz wrote.
In the new study, the average age of patients was 52.5; fourteen were women. Most were treated in large, urban emergency departments. For Bobrovitz, most alarming were cases where the person had atypical, meaning none of the usual, symptoms. In one case, a patient arrived in emergency with shoulder pain. The pain resolved, vital signs were stable and, after a normal exam, the patient was discharged home — only to die the next morning of an aortic rupture.
“It’s those really atypical symptoms that make me nervous, because dissection is not the first thing I think about,” Bobrovitz said.
In another case, a patient arrived in emergency complaining of sudden onset chest pain after heavy lifting.
An ECG (electrocardiogram) was performed. Pain medication was prescribed. But no chest X-ray or blood work was ordered, the researchers reported.
“The patient was discharged within a few hours with a diagnosis of chest wall pain and subsequently died of an aortic dissection.”
Other cases included a person with sudden pain in the upper left flank, and difficulty breathing. “Due to volume and crowding, the patient was given pain medication and not assessed for several hours,” the study found. When finally assessed, the doctor documented no signs of respiratory distress, the pain seemed better and the patient was sent home with a diagnosis of back pain. The patient returned to ED later that same day with severe chest pain, was diagnosed with aortic dissection and died before getting surgery.
“Atypical features such as younger patient age, transient symptoms or seemingly benign causes of pain … frequently led clinicians astray,” the researchers wrote.
In 21 cases, “the outcome was decided against the physician.”
Not all complaints involving missed dissections are captured. Doctors “reach out to CMPA for support at their own discretion,” the researchers noted. And the high rate of misdiagnosis in Ontario hasn’t budged in over a decade.
A Canadian-developed tool called the RIPP Score can help emergency staff evaluate people with a suspected dissection. “It’s the most sensitive tool out there, meaning it catches most cases of dissection,” Bobrovitz said.
“It can really help with patients where it’s not super obvious but you’re thinking about maybe dissection.”
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