Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D‐Dimer Concentration

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute type A aortic dissection (ATAAD) (n=262). Intervention: Elevated admission D-dimer concentration (>8.3 μg/mL) vs. Low admission D-dimer concentration (≤8.3 μg/mL, lower quartile). Primary outcome: In-hospital mortality (OR 11.83, 95% CI 1.21-115.53, p=0.033).

Q: What does this research mean for the field?

In patients with acute type A aortic dissection undergoing surgery, an elevated admission D-dimer level (>8.3 μg/mL) is an independent predictor of increased in-hospital mortality and perioperative complications. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Ryo Itagaki; Naoyuki Kimura; Makiko Mieno; Daijiro Hori; Satoshi Itoh; Kei Akiyoshi; Koichi Yuri; Keisuke Tanno; Koji Kawahito; Atsushi Yamaguchi

doi:10.1161/jaha.118.009144

July 9, 2018Journal of the American Heart AssociationOpen Access

Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D‐Dimer Concentration

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Key result

Admission D-dimer >/mL linked to ~11.8-fold higher in-hospital mortality in type A aortic dissection.

OR 11.83
95% CI 1.21-115.53
P=0.033
n=262

Figures

Why the study?

Does an elevated admission D-dimer concentration (>8.3 μg/mL) predict increased in-hospital mortality and adverse perioperative outcomes in patients undergoing urgent surgical repair for acute type A aortic dissection?

Key Points

To clarify the clinical characteristics, anatomical predictors, and treatment outcomes associated with preoperative D-dimer concentrations in patients with acute type A aortic dissection.
D-dimer concentration was measured preoperatively within 24 hours of symptom onset in 262 patients with acute type A aortic dissection.
Patients were categorized by admission D-dimer concentration into a lower-quartile group (≤8.3 μg/mL, n=66) and an elevated group (>8.3 μg/mL, n=196) to analyze clinical variables and surgical outcomes.
Median D-dimer concentrations differed by false lumen status: 5.0 (2.6–18.0) μg/mL for complete false lumen thrombosis (n=33), 8.7 (3.2–26.9) μg/mL for ulcerlike projection (n=17), 26.5 (10.0–70.6) μg/mL for a patent false lumen (n=131), and 60.9 (19.4–160.4) μg/mL for partial thrombosis (n=81) (P<0.01).
Multivariate analysis showed dissection limited to the ascending aorta (odds ratio, 9.81; P<0.01) or descending aorta (odds ratio, 7.68; P<0.01), a completely thrombosed false lumen (odds ratio, 4.02; P<0.01), and absence of brain ischemia (odds ratio, 4.74; P=0.013) to be predictors of lower D-dimer concentration (≤8.3 μg/mL).
In-hospital mortality was significantly higher in patients with D-dimer >8.3 μg/mL compared to ≤8.3 μg/mL (11.2% versus 1.5%; P=0.031), whereas 7-year survival did not differ significantly among hospital survivors (79.1% versus 93.1%; P=0.21).

Study Design

Type

Cohort (n=262)

Multicenter

No

Structured PICO

Does an elevated admission D-dimer concentration (>8.3 μg/mL) predict increased in-hospital mortality and adverse perioperative outcomes in patients undergoing urgent surgical repair for acute type A aortic dissection?

P

Population

262 adults (mean age 64.7 years, 45.4% female) in Japan who underwent urgent or emergency surgical repair for acute type A aortic dissection within 24 hours of symptom onset, followed for up to 7 years.

E

Exposure

Admission serum D-dimer concentration >8.3 μg/mL (n=196) measured preoperatively within 24 hours of symptom onset by turbidimetric immunoassay, prior to urgent or emergency surgical aortic repair via median sternotomy.

C

Comparator

Admission serum D-dimer concentration ≤8.3 μg/mL (lower quartile, n=66) prior to urgent or emergency surgical aortic repair.

O

Outcome

In-hospital mortality following urgent or emergency surgical repair for acute type A aortic dissection.hard clinical

Main Result

Odds Ratio: 11.83 (95% CI 1.21–115.53)

Absolute Event Rate: 11.2% vs 1.5%

p-value: p=0.033

In patients undergoing urgent repair for acute type A aortic dissection, admission D-dimer levels reflect the anatomical extent of dissection and false lumen thrombosis status, with levels >8.3 μg/mL independently predicting higher in-hospital surgical mortality and perioperative bleeding complications.

Limitations

Single-center retrospective study design
Lack of standardization across different D-dimer assays and monoclonal antibodies could lead to selection bias
Did not use the generally accepted 0.5 μg/mL diagnostic cutoff due to the specific measurement system used (detection limit <1 μg/mL)
D-dimer was not measured postoperatively to assess late outcomes
Lack of standardization of D-dimer assays across different monoclonal antibodies and measurement systems, which could lead to selection bias
Did not use the generally accepted 0.5 μg/mL cutoff for D-dimer testing due to the measurement system detection limit (<1 μg/mL)
Lack of postoperative D-dimer measurements to evaluate its utility in predicting late outcomes

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Answers are grounded in this paper and cite their sources.

Implication

May flag higher in-hospital mortality risk; leaves open incremental value for preoperative stratification in type A dissection.

Abstract

Background Clinical characteristics and treatment outcomes of acute type A aortic dissection with D‐dimer elevation have not been clarified. Methods and Results D‐dimer was measured preoperatively within 24 hours of symptom onset in 262 patients with acute type A aortic dissection . The median (and interquartile range) admission D‐dimer concentration in our total patient group was 26.7 (8.3–85.9) μg/ mL . Median (interquartile range) D‐dimer concentrations were 5.0 (2.6–18.0) μg/ mL for complete false lumen thrombosis (n=33), 60.9 (19.4–160.4) μg/ mL for partial thrombosis (n=81), 26.5 (10.0–70.6) μg/ mL for a patent false lumen (n=131), and 8.7 (3.2–26.9) μg/ mL for ulcerlike projection (n=17) ( P< 0.01). With a D‐dimer concentration of ≤8.3 μg/ mL representing the lower quartile, we then investigated predictors of a low D‐dimer level. Multivariate analysis showed dissection limited to the ascending aorta ( P< 0.01; odds ratio, 9.81) or descending aorta ( P< 0.01; odds ratio, 7.68), a completely thrombosed false lumen ( P< 0.01; odds ratio, 4.02), and absence of brain ischemia ( P= 0.013; odds ratio, 4.74) to be predictors of the lower D‐dimer concentration. Compared with patients with a low D‐dimer concentration (≤8.3 μg/ mL , n=66), patients with a D‐dimer concentration >8.3 μg/ mL (n=196) had a reduced preoperative platelet count and increased operation time and transfusion volume. In‐hospital mortality was elevated in this group (1.5% versus 11.2%; P= 0.031), although 7‐year survival did not differ for hospital survivors (lower versus higher, 93.1% versus 79.1%; P =0.21). Conclusions D‐dimer concentrations are strongly influenced by the extent of dissection and false lumen status. Operative risks are increased in patients with a relatively high D‐dimer concentration.

Discussion

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Cite This Study

Itagaki et al. (2018) conducted a cohort in Acute type A aortic dissection (ATAAD) (n=262). Elevated admission D-dimer concentration (>8.3 μg/mL) vs. Low admission D-dimer concentration (≤8.3 μg/mL, lower quartile) was evaluated on In-hospital mortality (OR 11.83, 95% CI 1.21-115.53, p=0.033). Admission D-dimer >8.3 μg/mL was associated with higher in-hospital mortality (11.2% vs 1.5%, p=0.031; adjusted OR 11.83, p=0.033) in surgically treated acute type A aortic dissection.

synapsesocial.com/papers/6a7472714b0395c886dbd37c https://doi.org/10.1161/jaha.118.009144

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Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D‐Dimer Concentration

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D‐Dimer Concentration

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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