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Dual-processing theory helps to explain delay in diagnosis of Stanford type A aortic dissection
  1. Alexander Moffat1,
  2. Francesco Formisano1,
  3. Helen Routledge1,
  4. Eleanor Bradbury2 and
  5. David Wilson1
  1. 1Department of Cardiology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
  2. 2College of Health, Life and Environmental Sciences, University of Worcester, Worcester, UK
  1. Correspondence to Dr Alexander Moffat; alexander.moffat{at}


A woman in her 70s presented with chest pain, which was initially thought to be an acute coronary syndrome but subsequently felt to be pericarditis. Chest radiography and echocardiography demonstrated striking cardiomegaly and marked biatrial dilatation, likely secondary to undiagnosed restrictive cardiomyopathy. The patient remained well on the ward for some days with only mild discomfort and stable haemodynamics. CT of the thorax went on to unexpectedly demonstrate a Stanford type A aortic dissection. The patient was promptly transferred for emergent surgery but sadly died intraoperatively.

Delayed or missed diagnosis of acute aortic dissection (AAD) is common. The dual-processing theory (DPT) of human judgement can be applied to medical decision making and used to explain this potential for diagnostic error in AAD diagnosis. A greater awareness of DPT and the role of heuristics and biases in medical decision making may help to reduce medical diagnostic error.

  • Cardiovascular medicine
  • Radiology

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  • Contributors HR and DW are cardiology consultants who jointly cared for the patient from when she was admitted to our centre prior to transfer for surgery and were involved in reviewing the completed manuscript. DW supervised the writing of the manuscript. AHM is a junior doctor in the cardiology team who took the lead in researching and writing the manuscript, incorporating other authors’ review comments and preparing it for submission. FF is a cardiology consultant with interest in cardiac imaging who reported the echocardiogram and provided expert insight into this and the CT thorax images; he also contributed to and was involved in review of the final manuscript. EB is a professor of psychology with an interest in health psychology who assisted with the health psychology aspects of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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