Accuracy of aortic dissection detection risk score alone or with D-dimer: A systematic review and meta-analysis

Abstract

Background: To evaluate the diagnostic accuracy and clinical utility of the acute aortic dissection detection risk score (ADD-RS) alone or with D-dimer as a screening test to exclude acute aortic syndrome. Methods: We conducted a systematic review and meta-analysis of studies examining the diagnostic accuracy of ADD-RS. We searched MEDLINE, Embase and Cochrane Controlled Register of Trials up to 12 December 2018. Results: We identified nine studies involving 26,598 patients for ADD-RS alone and 3421 patients with D-dimer. Overall, the methodological quality based on the Quality Assessment of Diagnostic Accuracy Studies 2 was moderate to high. Bivariate meta-analyses showed that the pooled sensitivities were 0.94 (95% confidence interval (CI) 0.90, 0.96) at the threshold of ADD-RS ≥1, 0.46 (95% CI, 0.34, 0.59) at ADD-RS ≥2, 1.00 (95% CI 0.99, 1.00) at ADD-RS ≥1 with D-dimer and 0.99 (95% CI 0.97, 1.00) at ADD-RS ≥2 with D-dimer. For the low prevalence population, failure rate and efficiency were 0.8% and 38.3% at ADD-RS ≥1, 0.03% and 14.5% at ADD-RS ≥1 with D-dimer, and 0.1% and 33.6% at ADD-RS ≥2 with D-dimer, respectively. For the high prevalence population, failure rate and efficiency were 3.8% and 33.3% at ADD-RS ≥1, 0.2% and 12.3% at ADD-RS ≥1 with D-dimer and 0.6% and 28.4% at ADD-RS ≥2 with D-dimer, respectively. Conclusions: ADD-RS alone or with D-dimer was a useful screening test with high sensitivity to exclude acute aortic syndrome. However, the optimal threshold of ADD-RS alone or with D-dimer may depend on the clinical setting.

Development of a Computerized, Evidence-Based Decision Support System for Computed Tomography Assessment in Acute Aortic Syndrome in the Emergency Department

“…We think it is appropriate to perform a chest X-ray in patients with intermediate or low risk as it provides an alternative diagnosis in 37% of these patients. We added D-dimer measurement in patients who are low or intermediate risk, based on the results of a recent metaanalysis [18] that showed that adding this to ADD-RS reduced the error rate in these groups.…”

MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

“…These associated processes are characterized by dynamic damage to the different components of the aortic wall ( Figure 3 A) and may coexist, rendering it impossible to know which came first ( Figure 3 B,C). The aortic dissection validated detection risk score (ADD-RS) is a clinical decision tool that aids in grading the pretest probability of an acute aortic dissection to reduce the rate of misdiagnosis, ranging from 0 to 3 [ 25 , 28 , 29 ]. In the ADvISED Prospective Multicenter Study, the integration of ADD-RS = 0 or ≤1 with D-dimer (DD) < 500 ng/mL shows negligible statistical heterogeneity and consistently high sensitivity, thus supporting reliability for the diagnostic rule-out of AAS ( Figure 4 ) [ 28 ].…”

Diagnosis and management of acute aortic syndromes in the emergency department

“…Assuming a prevalence of AASs of 20%, ADD-RS≥1 has a failure rate of 3.8%, corresponding to 1 missed case in 26 patients. [32] Assuming a prevalence of 5%, the failure rate is 0.8%, corresponding to 1 missed case in 125. Hence, even in case of lower pre-test probability, ADD-RS per se is insufficient to safely rule-out the disease.…”

“…Several studies have shown that D-dimer levels robustly increase in AASs. [2,32,49,50] At present, the only validated D-dimer cut-off for AASs is 500 ng/mL FEU, while only preliminary data have been provided for an age-adjusted cut-off. [14, 50, 51] D-dimer is characterized by high sens and low to moderate spec due to unspecific increase with age, cancer and several diseases in differential diagnosis (e.g.…”