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