Utilizing the national early warning score in patients with acute aortic dissection: Current applications and potential challenges

Acute aortic dissection (AAD) is a life-threatening condition characterized by a tear in the aortic intima, leading to blood entering the aortic wall and creating a false lumen. This condition requires prompt diagnosis and management due to its high morbidity and mortality rates. The National Early Warning Score (NEWS) is a tool initially developed to improve the early detection of patient deterioration by quantifying physiological measurements and assigning a score to predict outcomes such as mortality, need for intensive care or cardiac arrest (Covino et al., 2023; Guzelce et al., 2023; Sanz-García et al., 2023). In recent years, the application of NEWS in the context of AAD has gained attention. Given the rapid progression and the complex management required for AAD, utilizing an effective early warning system can significantly enhance clinical decision-making processes. We read with great interest the recent article by Langkjaer and colleagues (Langkjaer et al., 2023) titled ‘How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: A fieldwork study’. The authors aimed to explore and describe how the NEWS and Individual Early Warning Score (I-EWS) are used and how they support nurses' patient risk assessment practice. The findings demonstrated that EWS systems support nurses' patient risk assessment practice, providing useful information. We are writing to express my interest and explores the current applications of NEWS in patients with AAD, highlight potential challenges and suggest strategies for research and practice.

AAD is a time-sensitive medical emergency that requires rapid diagnosis and intervention to prevent mortality. The use of NEWS in patients with AAD can facilitate early detection of clinical deterioration, enabling prompt management and potentially improving outcomes. The NEWS system evaluates six physiological parameters: respiratory rate, oxygen saturation, systolic blood pressure, heart rate, level of consciousness and temperature, each scored from 0 to 3 based on deviation from normal ranges (Guzelce et al., 2023). (1) Early detection and risk stratification: The primary advantage of utilizing NEWS in patients with AAD is its ability to facilitate early detection and risk stratification. NEWS incorporates vital signs such as respiratory rate, oxygen saturation, temperature, systolic blood pressure, heart rate and level of consciousness, which are critical parameters in assessing hemodynamic stability (Guzelce et al., 2023; Sanz-García et al., 2023). In the emergency setting, where AAD symptoms might mimic other less severe conditions, NEWS can aid in distinguishing patients who require urgent intervention. (2) Facilitating communication among healthcare providers: NEWS serves as a standardized communication tool among healthcare providers. In the context of AAD, timely communication is crucial for mobilizing multidisciplinary teams, including cardiologists, cardiothoracic surgeons and anaesthetists. By providing a quantifiable measure of patient acuity, NEWS helps prioritize cases and allocate resources efficiently. (3) Guiding clinical management: The NEWS can guide clinical management decisions by indicating the severity of illness. Patients with high NEWS scores may require more aggressive monitoring and treatment, such as advanced imaging, pharmacological management to control blood pressure and consideration for surgical intervention. This approach ensures that patients receive the appropriate level of care based on their physiological status (Guzelce et al., 2023).

Despite its advantages, the use of NEWS in patients with AAD presents several challenges (Guzelce et al., 2023; Holland & Kellett, 2023; Sanz-García et al., 2023): (1) Limitations in sensitivity and specificity: While NEWS is valuable in assessing general patient deterioration, its sensitivity and specificity in predicting AAD-specific outcomes are limited. AAD may present with atypical symptoms or transient stability, leading to lower NEWS scores despite significant underlying pathology. This limitation highlights the need for complementary diagnostic tools and clinical judgement in evaluating suspected AAD cases. (2) Integration with diagnostic imaging: AAD diagnosis heavily relies on imaging modalities such as computed tomography angiography, magnetic resonance imaging or transesophageal echocardiography. The integration of NEWS with imaging findings can be challenging, as imaging availability and interpretation require time and specialized expertise. Balancing the urgency indicated by NEWS with the need for confirmatory imaging is a critical aspect of AAD management. (3) Variability in clinical presentation: The clinical presentation of AAD can vary widely, from classic symptoms such as chest pain and syncope to atypical presentations mimicking other conditions like myocardial infarction or stroke. This variability poses a challenge in relying solely on NEWS for early detection and underscores the importance of comprehensive clinical assessment. (4) Resource limitations in emergency settings: Implementing NEWS in resource-limited emergency settings can be challenging due to constraints in staffing, training and infrastructure. Ensuring that all healthcare providers are proficient in using NEWS and interpreting its implications requires ongoing education and quality improvement initiatives.

To enhance the effectiveness of NEWS in the context of AAD, several strategies can be considered: (1) Tailored protocols: Developing AAD-specific protocols that incorporate NEWS can help tailor the assessment to the unique needs of these patients. (2) Enhanced training programs: Implementing training programs that focus on recognizing the signs of AAD and understanding the limitations of NEWS can improve clinical outcomes. (3) Integration with advanced monitoring: Combining NEWS with advanced monitoring technologies, such as continuous blood pressure and heart rate monitoring, can provide a more comprehensive assessment of patient status. (4) Research and development: Ongoing research to refine and validate NEWS for specific conditions like AAD is essential to improve its predictive accuracy and clinical utility.

The NEWS holds promise as a tool for improving the early detection and management of patients with acute aortic dissection. Its ability to provide a standardized assessment of physiological derangement can facilitate timely intervention and resource allocation, ultimately improving patient outcomes. However, the limitations and challenges associated with its use must be carefully considered and addressed through ongoing research, training and protocol development. Future efforts should focus on optimizing NEWS for use in AAD, exploring its integration with other diagnostic tools, and establishing robust frameworks for clinical decision-making that incorporate both quantitative scores and clinical expertise. By leveraging the strengths of NEWS while addressing its limitations, healthcare providers can enhance the quality of care delivered to patients with this life-threatening condition.

Zhi-Qiang Yin and Dong-Mei Zou: Conceptualization, supervision, validation, writing—review and editing. All authors provided final approval for publication.

This work was supported by the Natural Science Foundation of Hunan Province of China (Grant No. 2024JJ9579).

The authors declare no conflicts of interest.

This article does not contain any studies with human participants or animals performed by any of the authors.

No consent for participation is required due to no personal data included.

No consent for publication is required due to no personal data included.