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:
- 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.
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
