Soluble ST2 for Acute Aortic Dissection Diagnosis

Study Questions:

Can soluble ST2 (sST2), a biomarker related to cardiac injury, discriminate acute aortic dissection (AAD) from other causes of sudden-onset severe chest pain?

Methods:

Plasma concentrations of sST2 were measured in 1,360 patients, including 1,027 participants in retrospective discovery sets and 333 patients with initial suspicion of AAD enrolled in a prospective validation cohort. Measures of discrimination were calculated for differentiating AAD from other causes of chest pain, including acute myocardial infarction (AMI) and pulmonary embolus (PE). In the retrospective discovery sets, sST2 was compared between patients with AAD and AMI with symptom onset within the first 24 hours, and between AAD and PE with symptom onset within 14 days.

Results:

In the case-control discovery sets, sST2 levels were higher in patients with AAD than in those with AMI (median 129.2 ng/ml vs. 14.7, p < 0.001), and in patients with PE (median 88.6 vs. 9.3, p < 0.001). In the prospective validation set, sST2 was most elevated in patients with AAD (median [interquartile range] 76.4 [49.6, 130.3]), and modestly elevated in patients with AMI (25.0 [15.5, 37.2]), PE (14.9 [10.2, 30.1]), and angina (21.5 [13.1, 27.6]; all p < 0.001 vs. AAD). The areas under receiver operator curves for AAD patients versus all control patients within 24 hours of presenting to the emergency department were 0.97 (0.95, 0.98) for sST2, 0.91 (0.88, 0.94) for D-dimer, and 0.50 (0.44, 0.56) for cardiac troponin I (cTnI), respectively. At a cutoff level of 34.6 ng/ml, sST2 had a sensitivity of 99.1%, specificity of 84.9%, positive predictive value of 68.7%, negative predictive value of 99.7%, positive likelihood ratio of 6.6, and negative likelihood ratio of 0.01.

Conclusions:

Among patients with suspected AAD in the emergency department, sST2 showed superior overall diagnostic performance compared to D-dimer or cTnI. The authors concluded that additional study is needed to determine if sST2 might be a useful “rule-out” marker for AAD in the emergency room.

Perspective:

sST2 is a cardiovascular injury-related biomarker. These data suggest that sST2 can be useful in the discrimination of AAD and other causes of acute chest pain, including AMI and PE.

Clinical Topics: Acute Coronary Syndromes, Prevention, ACS and Cardiac Biomarkers

Keywords: Acute Coronary Syndrome, Angina Pectoris, Biological Markers, Chest Pain, Dissection, Embolism, Emergency Service, Hospital, Myocardial Infarction, Primary Prevention, Troponin I, Vascular Diseases


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