Picture the following encounter: A 52-year-old male presents with chest pain. He seems comfortable and is slightly hypertensive to 156/83, but the rest of his vital signs are normal. He admits to using cocaine prior to the onset of chest pain. He denies any radiation of pain or other associated symptoms. When you are going through your differential, you consider aortic dissection, and you wonder if there are any tools to help you decide if this patient should get a CT angiography (CTA) study to further evaluate for aortic dissection.
The presentation of aortic dissection is highly non-specific and variable. Yet, CTAs expose patients to radiation and large doses of IV contrast, so it is not reasonable to order one on every chest pain patient in the ED.
Some of the more significant predictive symptoms for dissection include:
Immediate onset of chest pain;
Severe pain;
Tearing or ripping pain;
Posterior chest or lower back pain;
Focal neurologic signs;
Pulse and/or blood pressure differentials;
Acute renal failure; and
Mediastinal or aortic widening on chest x-ray (1).
A note on mediastinal or aortic widening on chest x-ray: This imaging finding is only about 60% sensitive. Therefore, mediastinal widening is frequently not present on initial chest x-ray (2).
Figure 1. Analysis of signs and symptoms associated with types A and B acute aortic dissections.
Are there any validated predictive clinical tools for aortic dissection?
Disclaimer: These clinical tools should not be used in any high-risk patient or in patients who have a high pretest probability for dissection.
Aortic dissection detection risk score (ADD-RS)
A validated bedside tool that helps assess the likelihood of acute aortic dissection before testing. It considers criteria such as chest, back, or abdominal pain that is sudden, severe, and feels like ripping or tearing. It also considers other high-risk conditions, such as a family history of aortic disease, known aortic valve disease, or recent aortic manipulation. The ADD-RS scores range from 0–3, with 0 being low risk, 1 being moderate risk, and 2–3 being high risk.
ADD-RS recommendations:
0-1 points: Obtain a D-Dimer
2-3 points: Proceed to CTA
Figure 2. MD Calc ADD-RS calculator. https://www.mdcalc.com/calc/4060/aortic-dissection-detection-risk-score-add-rs
Why does the ADD-RS recommend D-dimer in patients with low or moderate risk?
D-dimers are well established as a biomarker for ruling out pulmonary embolism (3,4), but several studies have shown that a d-dimer is also highly sensitive for aortic dissection (5,6). However, a negative d-dimer is insufficient to rule out dissection alone (7,8).
ADD-RS + D-dimer
The ADvISED Trial, also known as the Aortic Dissection Detection Risk Score Plus D-Dimer in Suspected Acute Aortic Dissection trial, presented a possible diagnostic approach for acute aortic dissection. It evaluated the utility of the AAD-RS in combination with D-dimer testing to rule out aortic dissection. Patients were eligible if they had at least one of the following: chest pain, abdominal pain, back pain, syncope, or a perfusion deficit. They were included in the study if dissection was in the differential diagnosis by the attending physician, ultimately determining the need for rule out of aortic dissection. The primary outcome was failure rate of the ADD-RS negative and D-dimer negative strategy. In 294 patients with ADD-RS score of 0 and a D-dimer <500ng/mL there was 1 case of dissection for a failure rate of 0.3% (7). The study concluded that this combination strategy could potentially safely rule out aortic dissection in a substantial proportion of patients, thereby reducing unnecessary imaging and improving diagnostic efficiency in emergency settings.
Figure 3. Proposed diagnostic algorithm based on pretest probability assessment and D-dimer from ADvISED Trial.
Disclaimer: While the ADD-RS score is validated, the proposed ADD-RS + D-dimer approach from the ADvISED Trial is not validated.
Takeaway Points:
The ADD-RS + D-dimer clinical approach for assessing patients at risk of aortic dissection needs further validation from external sources to confirm its reliability and effectiveness compared to conventional clinical judgment, prior to being integrated into routine clinical practice. The Aortic Dissection Detection Risk Score (ADD-RS) can be used for low- to moderate-risk patients for whom acute aortic dissection is in the differential diagnosis. ADD-RS and D-dimer are not meant to diagnose dissection, but rather to provide guidance in risk-stratifying patients for imaging.
Authored by Taylor Wahrenbrock, MD and Kathryn McGregor, MD.
References:
von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical Prediction of Acute Aortic Dissection. Arch Intern Med. 2000;160(19):2977–2982. doi:10.1001/archinte.160.19.2977
von Kodolitsch Y, Nienaber CA, Dieckmann C, et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116(2):73-77. doi:10.1016/j.amjmed.2003.08.030
Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, Rutschmann OT, Sanchez O, Jaffrelot M, Trinh-Duc A, Le Gall C, Moustafa F, Principe A, Van Houten AA, Ten Wolde M, Douma RA, Hazelaar G, Erkens PM, Van Kralingen KW, Grootenboers MJ, Durian MF, Cheung YW, Meyer G, Bounameaux H, Huisman MV, Kamphuisen PW, Le Gal G. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311:1117–1124. doi: 10.1001/jama.2014.2135.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35:3033–3069, 3069a. doi: 10.1093/eurheartj/ehu283.
Watanabe H, Horita N, Shibata Y, Minegishi S, Ota E, Kaneko T. Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects. Sci Rep. 2016;6:26893. doi: 10.1038/srep26893.
Asha SE, Miers JW. A systematic review and meta-analysis of D-dimer as a rule-out test for suspected acute aortic dissection. Ann Emerg Med. 2015;66:368–378. doi: 10.1016/j.annemergmed.2015.02.013.
Diercks DB, Promes SB, Schuur JD, Shah K, Valente JH, Cantrill SV. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015;65:32–42 e12.
Baez AA, Cochon L. Improved rule-out diagnostic gain with a combined aortic dissection detection risk score and D-dimer bayesian decision support scheme. J Crit Care. 2017;37:56–59. doi: 10.1016/j.jcrc.2016.08.007.
Nazerian et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation 2017. PMID: 29030346