Value of D-Dimer and C Reactive Protein in Predicting Inhospital Death in Acute Aortic Dissection

Study Questions:

Are elevated D-dimer and C-reactive protein (CRP) levels associated with increased mortality in patients presenting with acute aortic dissection (AAD)?

Methods:

This single-center prospective study evaluated 114 consecutive patients presenting with AAD, and compared D-dimer levels, CRP levels, and clinical and imaging characteristics between patients who survived versus died during hospitalization, and who did not meet exclusion criteria. Exclusion criteria included those with coronary artery disease, heart failure, Marfan syndrome, recent surgery, or recent infectious disease.

Results:

From the total population of 114 patients, there were 31 deaths (27%) during hospitalization. Between those who survived versus died, there were no differences in mean age (49 ± 8 vs. 49 ± 8 years, p = 0.93) or male gender (83% vs. 87%, p = 0.42). Patients who survived versus died had smaller mean aortic diameters (40.3 ± 6.0 vs. 45.2 ± 9.5 mm, p = 0.007), lower mean D-dimer levels (4.3 ± 2.0 vs. 9.8 ± 3.5 ug/ml, p < 0.001), and lower CRP levels (11.2 ± 1.9 vs. 14.1 ± 2.8 mg/L, p < 0.001). Using a multivariable model, variables independently associated with mortality risk included an elevated D-dimer (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.6-6.5; p = 0.001), elevated CRP (OR, 2.3; 95% CI, 1.1-4.8; p = 0.02), and type B (vs. type A) AAD (OR, 0.13; 95% CI, 0.1-0.9; p = 0.03). The area under the curve for prediction of mortality was 0.82 using CRP alone, 0.92 using D-dimer alone, and 0.95 for using both D-dimer and CRP. Using optimized cutoffs, combined use of D-dimer and CRP values was 82% sensitive and 97% specific to identify patients with subsequent mortality.

Conclusions:

The authors concluded that in patients presenting with AAD, elevated CRP and D-dimer levels are associated with increased in-hospital mortality.

Perspective:

Biomarkers such as D-dimer have been demonstrated in several studies to help identify and exclude AAD. However, determining which patients are at increased risk of in-hospital mortality can be challenging, especially when the patient is initially presenting to the hospital. These findings suggest that combined use of D-dimer and CRP testing may be helpful to rapidly identify high-risk patients. It is unclear, however, whether these values add significant incremental benefit to other variables such as imaging findings, which may be available even before lab results are known. Further, the study excluded significant cohorts of patients—such as those with coronary artery disease or Marfan syndrome—which may limit the generalizability of these results. Future research is needed to evaluate the clinical utility of these biomarkers in a more generalizable population and in comparison to a larger number of additional variables, including imaging findings.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD & Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Odds Ratio, Coronary Artery Disease, C-Reactive Protein, Hospital Mortality, Biological Markers, Fibrin Fibrinogen Degradation Products, Heart Failure, Marfan Syndrome, Confidence Intervals, Epidermal Cyst


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