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.
- 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
- 1850 patients analyzed.
|Pre-test Probability Assessment||Patients|
- 13% had AAS
|Type A aortic dissection||125|
|Type B aortic dissection||53|
|Intramural aortic hematoma||35|
|Penetrating aortic ulcer||10|
High sensitivity of 99.6% = good for ruling out AAS
- Observational study with many confounders
- Half the patients did not have conclusive imaging
- 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.
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