The Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (Ƶ) are delighted to lend our enthusiastic support to the sixth World Patient Safety Day (WPSD). This event, established by the World Health Organisation (WHO) in 2019, takes place on 17 September every year. It helps to raise global awareness amongst all stakeholders about key Patient Safety issues and foster collaboration between patients, health care workers, health care leaders and policy makers to improve patient safety. Each year a new theme is selected to highlight a priority patient safety area for action.
The theme set by the WHO for this year’s WPSD is “Improving diagnosis for patient safety”, recognising the vital importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.
A correct and timely diagnosis is key to the patient accessing the care they need;delayed, incorrect or missed diagnoses often lead to harm.
Diagnostic safety can be improved by addressing systems-based issues (such as communication failures, heavy workloads, ineffective teamwork) andcognitive factors(such as clinical training, experience, predisposition to biases, fatigue and stress) that can lead to diagnostic errors.
Background
In health, theaorta isarobust biomechanical structureresponsible for piping blood from the heart to the rest of the body.Intwo,largely unpredictable,conditions-AorticAneurysm and Acute Aortic Dissection-aninherentweaknessin the aortic wall, predisposesto fatal rupture or other major life-threatening complications.
Aortic Aneurysmusuallyremainsasymptomaticand silent;often only presenting with sudden catastrophic rupture.Thereisgradualballooningof part of the aorta,andat a critical size,rupture.A ruptured aneurysm is associated withup to 80% overallmortalityand major morbidity in survivorsof emergency surgical repair anditremainsa leading causeof death in men >55years.
Acute Aortic Dissectionandother“Acute Aortic Syndromes”arerare (incidence 1 in 10,000annually), butcan be even moredevastatinganddifficult to diagnose.Theyaffectyounger patients of both sexesequally. Here, there issudden disruption of thestructure of theaortic wall, whereby its overall integrity is compromised.This may result inaortic ruptureandother major life-threateningcomplications andcarries a 50% mortality.Acute aortic syndromeincidenceis increasing andremainsunderdiagnosed.
When these conditions areidentifiedearly,the outcomes of aortic diseasetreatedelectively(prior to rupture or major complication)havesteadily improved andcurrently,electiveaortic aneurysmrepaircarriesa relativelylowriskof aneurysmrelated death. The rewards ofearly diagnosis anddetectionare high.
Diagnostic Challenge – Clinically
The major diagnostic challenge presented byaortic disease, is that itremainsasymptomatic and undetected until one of the catastrophesaboveoccur. Even when presenting with a rupture or dissection, symptoms can be vagueorrelatively benignin appearance, leadingtomisdiagnoses, before thediagnosisreveals itself– often too late-withadevastatingconsequences.
In spite ofincreasededucational effortsand thegreater availability of CT imaging than ever before(thecurrentdefinitive diagnostictest),recent studieshave shown that upto 30% of aorticdissections are still missed or diagnosed too late.An ongoing UK study into themisdiagnosis ofacuteaorticsyndromeshasidentifiedthe main reason for misdiagnosisas“atypical symptoms,false reassurances due to normal clinical findings, a reliance on investigations as ‘rule out’ tests, and a confirmatory bias towards investigations suggesting alternative diagnoses”.
Diagnostic Challenge – Imaging
CT scan is the favoured and gold standard diagnostic modality for the patient in the emergency department, but it is nota practicableuse of resourcesto CT scan every patient with atypical chest, back or abdominal pain.
In the outpatient setting,aortic diameter is the main means of monitoring disease progression, butthisisanimprecisepredictor of riskof rupture.Therefore,abiomarkerfor aortic diseaseto aid diagnosis and risk stratification in aortic diseaseisregarded as an internationalresearch priority.
The Need for Biomarkers to Aid Clinical Diagnosis
The idealaorticbiomarkerisa sensitive and specific blood testthat will clearlyidentifyan acute aorticevent,andsignala ‘high risk’ aorta to theclinician.
Over the years, our group and others have investigated several serum biomarkers, some of which appear to correlate with acute aortic syndrome, but none havetranslatedto be clinically relevant or reliableat detecting an unstable aorta.Our workis ongoing, investigatingnew candidateserumbiomarkersand harnessing novel genomic technologies toidentifypotential genetic biomarkersof aortic disease activity.
Understanding the underlying biological mechanismsof aortic disease is also vital toidentifyunderlying molecular pathways and therefore diagnostic and therapeutic targets. We have therefore created theEdinburgh Vascular biobank,which we hope to make a Pan-Scotland initiative as part of the Scottish Biorepository network, to biobank aortic tissue,bloodand DNA from this rare but high priority patient group.