Diagnostic accuracy of point-of-care ultrasound for the detection of acute aortic syndrome and thoracic aortic aneurysm in the emergency department: systematic review and meta-analysis

Background Acute aortic syndromes (AAS) are a group of aortic disorders with a wide range of presentations that are easily misdiagnosed in emergency departments. The European Society of Cardiology Guidelines 2024 recommend focused transthoracic echocardiography as the first-line imaging tool for the detection of aortic dissection, but the performance of point-of-care ultrasound (POCUS) in detecting AAS in emergency settings varies considerably in the existing literature. Purpose To gather and synthesize existing studies to provide a more comprehensive overview of the diagnostic accuracy and value of POCUS for the detection of AAS and its generalizability in the emergency department setting. Methods We searched Ovid MEDLINE, EMBASE, Web of Science, and the Cochrane Library for relevant studies published from 1 January 2000 to 31 December 2024. Studies involving adults in which POCUS was performed in emergency departments and reporting the diagnostic accuracy of POCUS for the detection of AAS were included by independent reviewers. Studies published in languages other than English without available translations, as well as case reports, reviews, and editorials without original data, were excluded. Two independent reviewers used the QUADAS-2 tool to assess the quality of the included studies and synthesized the data using a random-effects model. This systematic review and meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, and the protocol is registered on PROSPERO. Results Of 390 studies identified in the literature search, eight prospective and retrospective studies (n = 4937) were included in the meta-analysis. For any sonographic signs for detecting AAS, the pooled sensitivity and specificity of POCUS were 88% (95% CrI, 85% - 91%) and 80% (95% CrI, 63% - 93%) respectively. The areas under the summary receiver operating characteristic curve for detecting type A AAS and type B AAS were 0.95 (95% CrI 0.70 – 0.98) and 0.88 (95% CrI 0.60 – 1.00), respectively. Heterogeneity was low for studies investigating the sensitivity of any sonographic signs in detecting all types of AAS (I2 = 0% - 15%) and high for studies investigating the specificity of any sonographic signs in detecting all types of AAS (I2 = 71% - 98%). Conclusion This systematic review found that POCUS potentially shortens the time to diagnosis in emergency departments given its high specificity. The absence of direct sonographic signs seems to be promising in ruling out AAS in combination with a negative D-dimer test. These findings suggest that emergency physicians should consider using POCUS as an initial imaging tool in assessing the aorta before more complex and costly investigations such as computed tomographic aortography and D-dimer testing should be considered for incorporation into emergency department workflows for possible AAS.