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Three Part Question

What is the [diagnostic accuracy of the aortic dissection detection risk score (ADD-RS) plus D-dimer (DD)] as a [screening test] in [emergency department patients suspected of acute aortic syndrome]?

Clinical Scenario

A 65-year-old male with a history of hypertension, hyperlipidemia, stage 4 chronic kidney disease (CKD) and daily smoking presents to the emergency department (ED) complaining of chest pain. Vitals show that he is hypertensive with a blood pressure (BP) of 170/95, with otherwise normal vitals. He has no neuro deficits. Workup completed shows an EKG with a normal sinus rhythm and non-specific ST-T wave changes but without evidence of acute ischemia. Troponins are normal. You wonder if he may have an aortic dissection, but he is well-appearing without neuro deficits and equal pulses. Given his CKD you wonder if there is a way to rule out an acute aortic syndrome without having to give a contrast load for a computed tomography (CT) angiogram. Will using the aortic detection risk score in conjunction with a d-dimer help either rule out or increase suspicion for acute aortic syndrome?

Search Strategy

Medline 1966-07/21 using PubMed, Cochrane Library (2021), and Embase
[(exp aortic dissection detection risk score) AND (exp d dimer)].

Search Outcome

16 studies were identified; two recent meta-analyses answered the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bima P. et. al. Oct 2020 Italy/Japan	Four articles (3804 patients) of adults with low clinical probability of acute aortic syndrome (AAS) with common presenting symptoms of AAS, such as chest pain, abdominal pain, syncope, or perfusion deficit.	Meta-analysis	Pooled sensitivity and failure rate of ADD-RS = 0 and DD < 500ng/mL	Pooled sensitivity: 99.9%; failure rate: 0.1%	Differential verification bias, with some patients included that had clinical follow up without advanced aortic imaging; Majority of patients in the studies had chest pain making the test less applicable to patients with other presenting symptoms; significant heterogeneity.
			Pooled sensitivity and failure rate of ADD-RS less than or equal to 1 and DD less than 500ng/mL	Pooled sensitivity: 98.9%; failure rate: 0.6%
			Pooled sensitivity and failure rate of ADD-RS = 0 and DD less than age-adjusted DD	Pooled sensitivity: 99.9%; failure rate: 0.1%
			Pooled sensitivity and failure rate of ADD-RS less than or equal to 1 and DD less than age-adjusted DD	Pooled sensitivity: 97.6%; Failure rate: NA because of significant heterogeneity
Tsutsumi Y. et. al. January 2020 Japan	9 studies (26,598 patients with ADD-RS alone and 3421 patients with ADD-RS plus DD) suspected of having AAS who presented with chest pain, back pain, abdominal pain, syncope, or perfusion deficit.	Meta-analysis	Pooled sensitivity and specificity of ADD-RS greater than or equal to 1 or D-dimer less than 500ng/mL	Sensitivity: 1.00, specificity: 0.15	Some studies excluded patients who did not have a index test or reference standard which could result in higher risk of bias in patient selection.
			Pooled sensitivity and specificity of ADD-RS greater than or equal to 2 or D-dimer greater than 500ng/mL	Sensitivity: 0.99, specificity: 0.35

Comment(s)

Acute aortic syndrome (AAS) is a rare but deadly spectrum of disease and when it occurs it can be difficult to differentiate those who should undergo more definitive testing especially in patients with low clinical probability who have non-specific symptoms. The above studies have shown that using the ADD-RS plus a d-dimer may be a way to rule out AAS and decrease unnecessary testing with CT scanning. However, there are few studies and this may only be applicable to patients specifically with chest pain as the majority of patients had this as there presenting symptom. It would difficult to apply this testing as a rule out of AAS in patients who had no chest pain but other presenting symptoms suspicious for AAS.

Clinical Bottom Line

An ADD-RS less than or equal to 1 plus a D-dimer less than 500ng/mL may be helpful in ruling out acute aortic syndrome in patients with low clinical probability who present with chest pain. Additionally, this still needs further external validation as there are a limited number of studies evaluating this. Further studies may be necessary, as well, to better assess whether the age-adjusted D-dimer can also be used in conjunction with the ADD-RS.

References

1. Bima P, Pivetta E, Nazerian P, Toyofuku M, Gorla R, Bossone E, Erbel R, Lupia E, Morello F. Systematic Review of Aortic Dissection Detection Risk Score Plus D-dimer for Diagnostic Rule-out Of Suspected Acute Aortic Syndromes Acad Emerg Med 2020 Oct;27(10):1013-1027
2. Tsutsumi Y, Tsujimoto Y, Takahashi S, Tsuchiya A, Fukuma S, Yamamoto Y, Fukuhara S. Accuracy of aortic dissection detection risk score alone or with D-dimer: A systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2020 Oct;9(3 suppl):S32-S39.