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. 2023 Mar 10;59(3):548.
doi: 10.3390/medicina59030548.

Pre-Test Probability Assessment and d-Dimer Based Evaluation in Patients with Previous Acute Aortic Syndrome

Fulvio Morello  1   2 , Marco Santoro  1 , Francesca Giachino  1 , Francesca Caciolli  1 , Elisa Capretti  3 , Matteo Castelli  3 , Emanuele Pivetta  1   2 , Peiman Nazerian  3 , Enrico Lupia  1   2
Affiliations

Pre-Test Probability Assessment and d-Dimer Based Evaluation in Patients with Previous Acute Aortic Syndrome

Fulvio Morello et al. Medicina (Kaunas). .

Abstract

Background and Objectives. Acute aortic syndromes (AASs) are emergencies burdened by high morbidity and mortality. Guideline-recommended diagnostic workup is based on pre-test probability assessment (PPA) and d-dimer testing. However, the performance of PPA and d-dimer has never been studied in individuals with previous AAS (pAAS), which represent a challenging population. Materials and Methods. We analyzed a registry of patients with pAAS evaluated in two Emergency Departments (EDs) for suspected novel AAS (nAAS). Enrolment criteria were history of pAAS and the presence of truncal pain, syncope or perfusion deficit. All patients underwent advanced imaging. Clinical data were registered prospectively and PPA was performed by applying the aortic dissection detection (ADD) and an aorta simplified (AORTAs) score. Results. A total of 128 patients were enrolled, including 77 patients with previous Stanford type A aortic dissection and 45 patients with previous Stanford type B aortic dissection. The final diagnosis was nAAS in 40 (31%) patients. Clinical variables associated with nAAS were: aortic valve disease, thoracic aortic aneurysm, severe pain, sudden pain, ripping/tearing pain and hypotension/shock. ADD score ≥ 2 had a sensitivity of 65% and a specificity of 83% for nAAS; AORTAs score ≥ 2 had a sensitivity of 48% and a specificity of 88%. d-dimer (cutoff ≥ 500 ng/mL or age-adjusted cutoff) had a sensitivity of 97% and a specificity of 13%/14.7%, for diagnosis of nAAS. Patients that were candidates for guideline-compliant PPA/d-dimer integrated rule-out were: 5 (4.9%) with ADD ≤ 1/d-dimer and 8 (7.8%) with AORTAs ≤ 1/d-dimer < age-adjusted cutoff. None of them had a nAAS. Conclusions. Patients with pAAS evaluated in the ED for red-flag symptoms showed intermediate-to-high pre-test probability of nAAS. The ADD score had lower sensitivity and specificity than in unselected patients. d-dimer, alone and integrated with PPA, was highly sensitive for nAAS, but very unspecific. PPA/d-dimer integrated strategies are unlikely to significantly reduce the number of patients with pAAS undergoing advanced imaging.

Keywords: acute aortic syndrome; aortic dissection; clinical score; d-dimer; diagnosis.

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Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; and in the decision to publish the results.

Figures

Figure 1
Figure 1
ROC curve of ADD (blue line) and AORTAs (red line) score for diagnosis of novel acute aortic syndrome.
Figure 2
Figure 2
(a) d-dimer levels in study patients with novel acute aortic syndrome (nAAS) and alternative diagnosis (AltD). (b) d-dimer levels in study patients with nAAS, classified by disease subtype. dn: de novo acute aortic syndrome; fle: false lumen extension; dil: aortic dilatation; pro: prosthetic complication; rupt: aortic rupture. (c) ROC curve of d-dimer for diagnosis of novel acute aortic syndrome.
Figure 3
Figure 3
Decision curve analysis of guideline-compliant integrated rule-out rules. Blue line: treat all; red line: treat none; green line: ADD ≤ 1/d-dimer <500 ng/mL; orange line: AORTAs ≤ 1/d-dimer < age-adjusted cutoff.
See this image and copyright information in PMC

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