Key result
In patients with previous acute aortic syndrome, d-dimer testing was highly sensitive (97%) but very unspecific (13-14.7%) for diagnosing novel acute aortic syndrome.
Why the study?
The performance of guideline-recommended pre-test probability assessment and d-dimer testing had never been studied in patients with previous acute aortic syndrome.
Do pre-test probability assessment and d-dimer testing accurately diagnose or rule out novel acute aortic syndrome in patients with previous acute aortic syndrome?
Observational (n=128)
Yes
Do pre-test probability assessment and d-dimer testing accurately diagnose or rule out novel acute aortic syndrome in patients with previous acute aortic syndrome?
In patients with previous acute aortic syndrome, d-dimer testing and pre-test probability scores are highly sensitive but very unspecific, meaning they are unlikely to safely reduce the need for advanced imaging.
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.
No takes yet. Share an insight, caveat, or question.
Morello et al. (2023) conducted an observational in Suspected novel acute aortic syndrome in patients with previous acute aortic syndrome (n=128). Pre-test probability assessment (ADD and AORTAs scores) and d-dimer testing was evaluated on Diagnosis of novel acute aortic syndrome (nAAS). In patients with previous acute aortic syndrome, d-dimer testing was highly sensitive (97%) but very unspecific (13-14.7%) for diagnosing novel acute aortic syndrome.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: