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Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes
Study Questions:
What is the diagnostic accuracy of pretest probability assessment (PPA) using the aortic dissection detection risk score (ADD-RS) in conjunction with assessment of D-dimer for the diagnosis of acute aortic syndromes (AAS)?
Methods:
ADvISED is an international multicenter prospective observational study involving six hospitals in four countries from 2014 to 2016 intended to assess the performance of standardized strategies for the diagnosis of AAS in the emergency department. Inclusion criteria included ≥1 of the following: chest/abdominal/back pain, syncope, or perfusion deficit; and AAS in the differential diagnosis. Pretest probability assessment was evaluated using the aortic dissection detection risk score (ADD-RS, 0 to 3), per current guidelines. D-dimer was considered negative if <500 ng/ml. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or on 14-day follow-up. Outcomes were failure rate and efficiency of a diagnostic strategy ruling out AAS in patients with ADD-RS = 0 plus negative D-dimer, or ADD-RS ≤1 plus negative D-dimer.
Results:
Of 1,850 patients analyzed, 438 (24%) patients had ADD-RS = 0; 1,071 (58%) had ADD-RS = 1; and 341 (18%) had ADD-RS >1. A total of 241 (13%) patients had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive D-dimer test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6-98.6%) and a specificity of 64% (95% CI, 61.6-66.4%) for diagnosis of AAS; eight (3%) patients with AAS had a negative D-dimer. Of 294 patients with ADD-RS = 0 and negative D-dimer, there was one case of AAS, yielding a failure rate of 0.3% (95% CI, 0.1-1.9%) and efficiency of 15.9% (95% CI, 14.3-17.6%). Of 924 patients with ADD-RS ≤1 plus negative D-dimer, there were three cases of AAS, yielding a failure rate of 0.3% (95% CI, 0.1-1%) and efficiency of 49.9% (95% CI, 47.7-52.2%).
Conclusions:
Integration of ADD-RS (either ADD-RS = 0 or ADD-RS ≤1) with a negative D-dimer may be able to standardize the diagnostic rule-out of AAS.
Perspective:
AAS are rare and severe cardiovascular emergencies with nonspecific symptoms; both misdiagnosis and overtesting are clinical concerns, and standardized diagnostic strategies may help physicians balance these. Although D-dimer is highly sensitive for AAS, it is not specific, and therefore inadequate as a stand-alone test. This study found that a negative D-dimer (<500 ng/ml) in conjunction with an aortic dissection detection risk score (a bedside clinical tool for standardized pretest probability assessment) of 0 or 0-1 reliably excluded a diagnosis of AAS (with a failure rate of only 0.3%). One study limitation is that about half of patients did not undergo definitive diagnostic imaging, and the presence or absence of AAS was based on 14-day case adjudication. Of importance, an initial clinical suspicion for AAS still is required, and prospective testing of this algorithm across multiple practice environments would be of interest.
Keywords: Aneurysm, Dissecting, Aortic Aneurysm, Aortic Rupture, Autopsy, Cardiac Surgical Procedures, Chest Pain, Diagnosis, Differential, Diagnostic Errors, Diagnostic Imaging, Emergency Service, Hospital, Fibrin Fibrinogen Degradation Products, Hematoma, Risk Assessment, Syncope, Vascular Diseases
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