Algorithms and clinical decision-making tools for ruling out acute aortic syndrome in the emergency department: a narrative review

Acute aortic syndrome (AAS) remains one of the most challenging diagnoses for Emergency Physicians. Given the time-sensitive nature of this highly fatal disease state, rapid and accurate testing modalities and diagnostic algorithms are sorely needed to reduce the high rates of missed diagnoses in the emergency department (ED). Several clinical tools and scoring systems have been proposed over the past decade in an effort to assist physicians in achieving this end and thus improve overall patient morbidity and mortality with more prompt identification and subsequent intervention. These are often based on prior expert guidelines, high-risk clinical features well-established in AAS, biomarkers, imaging studies, and other metrics regularly obtained in the ED. Unfortunately, all algorithms and clinical decision-making tools currently available have yet to be externally, prospectively validated to provide a reliable, definitive means of either diagnosing or ruling-out AAS in the ED. However, research is ongoing, the literature remains rather robust, and continued efforts are underway to develop and validate an optimal tool for widespread, standardized use for this "never-miss" diagnosis in emergency medicine.