Cognitive biases and misdiagnosis of aortic dissection at emergency departments

BACKGROUND: Aortic dissection (AD) is still a challenging diagnosis with poor prognosis, and its misdiagnosis remains an unresolved problem. Postmortem examination has long been deemed important for understanding the diseases and determining the cause of death. We aim to investigate the concordance between clinical diagnosis and autopsy findings and to identify the most common clinical "red flags" and the cognitive errors involved in the management of AD. METHODS: This retrospective, observational, single-centre study analysed a series of 30 forensic autopsies focusing on the 7 cases of AD. Clinical-autopsy discrepancies were categorised into six predefined classes, and cognitive biases were classified into four types. All records were independently reviewed by two emergency physicians and two forensic pathologists, with consultation from a cognitive psychologist and consensus reached through collegial discussion. RESULTS: These seven patients had a mean age of 59 years (range 48-71 years). Loss of consciousness (4/7 patients), lumbar pain (4/7), psychomotor agitation (4/7) and two or more ER visits were considered red flags for AD. The most common malperfusion syndromes were coronary and femoral-iliac. Among the types of diagnostic errors, faulty verification bias was the most common, followed by biases related to faulty information processing. In three patients (43%), the failure to diagnose AD directly contributed to death, as an earlier diagnosis would likely have altered clinical management and improved survival outcomes. CONCLUSION: There remains a significant unmet need to increase awareness and clinical suspicion of AD in patients presenting with atypical symptoms, non-traditional risk factors, or ambiguous physical findings. Furthermore, identifying and sharing the cognitive underpinnings of errors may aid in reducing misdiagnosis and optimizing both the timing and modality of clinical management.