Cardiovascular emergencies such as ruptured abdominal aortic aneurysm (AAA), acute myocardial infarction (AMI), stroke, aortic dissection, or subarachnoid hemorrhage (SAH) are undiagnosed in fewer than 1 in 20 emergency department presentations, according to a study published in JAMA.

Daniel A Waxman, MD, PhD, of the Department of Emergency Medicine at the University of California, Los Angeles, and associates conducted a retrospective group analysis of all Medicare claims from 2006 until 2014 to project how many potential cases were left undiagnosed: the primary outcome was the ratio of undiagnosed to diagnosed patients.

The ratio consisted of the difference between the anticipated and observed ED discharge dates within 45 days of hospital admission (numerator) and the number of index hospital admissions (documented emergencies) and the undetected emergencies (excess discharges [denominator]).

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A total of 1,561,940 Medicare patients were included, 17,963 of whom were admitted for AAA, 304,980 for AMI, 1,181,648 for stroke, 19,675 for aortic dissection, and 37,674 for SAH. The average age of the admitted patients was 77.9 years (8.9% of individuals were younger than 65), and 54.1% were women.

Of the cohort, 3.4% of AAA cases, 2.3% of AMI cases, 4.1% of stroke cases, 4.5% aortic dissection, and 3.5% of SAH cases remained undiagnosed.

A multivariable analysis revealed variables correlated with lack of diagnoses, including age (patients younger than 65), dual eligibility for Medicare and Medicaid coverage, gender (female), and chronic conditions such as end-stage renal disease, dementia, depression, diabetes, hypertension, cerebrovascular disease, coronary artery disease, and chronic obstructive pulmonary disease. No improvements between 2007 and 2014 were reported.

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“The absence of improvement over the 8-year time frame of the study raises the question of whether our ability to diagnose these acute emergencies has reached a plateau,” the authors noted.

“Some researchers have mentioned a natural asymptote, where the costs or risks of seeking additional diagnostic certainty become prohibitive,” continued the authors. “More widespread application of probabilistic approaches—to other diagnoses and to other care venues—will require further methodological innovation but seems inevitable.”


  1. Waxman DA, Kanzaria HK, Schriger DL. Unrecognized cardiovascular emergencies among Medicare Patients. JAMA Intern Med. 2018 Feb 26. doi:10.1001/jamainternmed.2017.8628 [EPub ahead of print]