ADvISED Trial

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    ADvISED Trial

    Background: Acute aortic syndromes (AAS) include aortic dissection, intramural aortic hematoma, penetrating aortic ulcer and aortic rupture. AAS are rare but life threatening cardiovascular emergencies with non-specific clinical presentations, which results in overtesting and misdiagnosis. The ADvISED Trial introduces a new clinical strategy that combines a Pre-test Probability Assessment with a D-dimer to help physicians reduce overtesting and misdiagnosis of AAS.

    Study Design:

    • Multicenter, prospective observation study with 14-day follow-up.
    • Inclusion: >18 yo plus one of the following symptoms: chest/abdominal/back pain, syncope, perfusion deficit, or AAS in the differential diagnosis.
    • Pre-test Probability Assessment has 12 risk markers which can be calculated to a risk score of 0 to 3.
    • D-Dimer is defined as negative if <500ng/mL

    Results:

    • 1850 patients analyzed.
    Pre-test Probability Assessment Patients
    0 438 (24%)
    =1 1071 (58%)
    >1 341 (18%)

     

    • 13% had AAS
    AAS Type Patients
    Type A aortic dissection 125
    Type B aortic dissection 53
    Intramural aortic hematoma 35
    Aortic rupture 18
    Penetrating aortic ulcer 10

     

    High sensitivity of 99.6% = good for ruling out AAS

    Limitations:

    1. Observational study with many confounders
    2. Half the patients did not have conclusive imaging
    3. With a high sensitivity of 99.6%, the miss rate is still 1 in ~300 cases.

    Take home point:

    There is a new clinical strategy that combines a Pre-test Probability Assessment with D-dimer to help physicians reduce overtesting and misdiagnosis of AAS. However, further validation studies should be done before incorporating into clinical practice.

    Resource:

    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

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