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Accuracy of Ultrasound in Suspected Acute Aortic Syndromes
Study Questions:
What is the accuracy of focused cardiovascular ultrasound in patients with suspected acute aortic syndromes (AAS)?
Methods:
This was a predefined substudy from a multicenter prospective study (ADvISED) of patients with suspected AAS, in which patients underwent a targeted cardiovascular ultrasound (US) to evaluate for AAS. The presence of AAS was based on findings from advanced imaging, surgery, autopsy, or follow-up at 14 days. The US was performed by a physician with ≥1 year of experience in this specific US protocol, using ≥1 view by US. Direct signs of AAS were presence of an intimal flap, intramural hematoma, or penetrating ulcer; indirect signs were thoracic aorta diameter ≥4 cm, pericardial effusion, or aortic regurgitation by color Doppler.
Results:
A diagnosis of AAS was reported in 146 of 839 study patients (17%). Direct signs, only indirect signs, and negative findings on US were observed in 10%, 27%, and 63% of patients, respectively. A diagnosis of AAS was reported in 78% with direct US findings, 29% with indirect findings, and 3% with a negative US. This resulted in a sensitivity and specificity of 45% and 97% for direct US findings, and 89% and 75% for any US findings. The area under the receiver operator curve improved from 0.77 using aortic dissection detection risk score alone to 0.85 with the addition of direct US findings, and 0.88 with the addition of any US findings. The use of US in patients with low clinical probability (aortic dissection detection risk score ≤1) and a D-dimer <500 mg/ml had a diagnostic sensitivity of 100% and specificity of 59%.
Conclusions:
A focused US can improve our ability to identify and exclude patients with suspected AAS, particularly in patients with low clinical probability.
Perspective:
This study finds that a focused US looking for direct or indirect evidence of AAS can improve our ability to evaluate patients with suspected AAS. While any US evidence of AAS had a sensitivity of only 89%, this improved to 100% in patients with low clinical probability of AAS and a negative D-dimer. It must be noted that US was performed by physicians with ≥1 year of experience, and its diagnostic accuracy would expectedly be lower when performed by less experienced providers. Further studies validating this approach are needed, particularly in nontertiary care sites with less experience in this US approach. If validated, this approach could improve our ability to rapidly exclude AAS without advanced imaging in patients with low clinical probability and negative D-dimers.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and VHD, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound
Keywords: Acute Coronary Syndrome, Aneurysm, Dissecting, Aorta, Thoracic, Aortic Valve Insufficiency, Cardiac Surgical Procedures, Diagnostic Imaging, Hematoma, Pericardial Effusion, Pericardium, Sensitivity and Specificity, Ulcer, Ultrasonography, Vascular Diseases
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