Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta‐analysis

Ohle, Robert; Kareemi, Hashim; Wells, George A.; Perry, Jeffrey J.

doi:10.1111/acem.13360

Cited by 50 publications

(38 citation statements)

References 39 publications

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“…Only studies of Armstrong, Eagle and Enia report on an isolated pulse deficit with a combined sensitivity of 24% (95% CI 13% to 41%) and specificity of 92% (95% CI 86% to 96%), which is similar to our results 10. Klompas’ review article in 2002 reported a similar diagnostic accuracy for the combined variable of systolic BP differential/pulse deficit with a positive likelihood ratio of 5.7 (1.4–23) and a negative likelihood ratio of 0.7 (0.6–0.9).…”

Section: Discussionsupporting

confidence: 91%

Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department

Ohle²,

Perry

2018

Emerg Med J

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Section: Discussionsupporting

confidence: 91%

Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department

Ohle²,

Perry

2018

Emerg Med J

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“…The general diagnostic accuracy of CR for AASs was modest and lower than predicted, in spite of specialized, focused, and nonurgent evaluation of radiologic films by dedicated radiologists. In previous studies, the sensitivity of CR for AASs was highly variable (11%–94%), with a pooled sensitivity of 64% in a metanalysis of 13 studies comprising 1,337 patients . Most were retrospective case–control studies comparing AASs with selected AltD and were poorly representative of ED case mixes.…”

Section: Discussionmentioning

confidence: 99%

Integrated Use of Conventional Chest Radiography Cannot Rule Out Acute Aortic Syndromes in Emergency Department Patients at Low Clinical Probability

Nazerian

Pivetta

Veglia

et al. 2019

Academic Emergency Medicine

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Objectives: Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AASs) if the pretest clinical probability is low. However, the diagnostic impact of CR integration for the rule-in and rule-out of AASs is unknown. Methods:We performed a secondary analysis of the ADvISED multicenter study. Emergency department outpatients were eligible if an AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (ME) and other signs.Results: In 2014 through 2016, a total of 1,129 patients were enrolled and 1,030 were analyzed, including 48 (4.7%) with AASs. ADD-RS/ME and ADD-RS/any CR sign (aCRs) integration were more accurate than ADD-RS alone (area under the curve = 0.8 and 0.78 vs. 0.66, p < 0.001). The sensitivity and specificity of the integrated strategies were 66.7% (95% confidence interval [CI] = 51.5% to 79.9%) and 82.5% (95% CI = 79.9% to 84.8%) for ADD-RS/ME and 68.8% (95% CI = 53.6% to 80.9%) and 76.5% (95% CI = 73.7% to 79.1%) for ADD-RS/ aCRs, respectively. The sensitivity and specificity of CR per se were 54.2% (95% CI = 39.2% to 68.6%) and 92.4% (95% CI = 90.5% to 93.9%) for ME and 60.4% (95% CI = 45.3% to 74.2%) and 85.2% (95% CI = 82.9% to 87.4%) for aCRs. The agreement (j) between attending physicians and radiologists for ME was 0.44 (95% CI = 0.35 to 0.54). ADD-RS/ME rule-in (ADD-RS ≤ 1 and ME-present, or ADD-RS > 1) applied to 204 versus 130 patients with ADD-RS > 1, including 14 with AAS and 60 false-positives (FP). ADD-RS/aCRs rule-in (ADD-RS ≤ 1 and aCRs-present, or ADD-RS > 1) applied to 264 patients, including 15 with AAS and 119 FP. ADD-RS/ME ruleout (ADD-RS ≤ 1 and ME-absent) applied to 826 (80.2%) patients, including 16 with AAS (33.3% of cases). ADD-

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“…41 Based on previous data, in terms of specificity, we speculate that the ADD-RS/DD rule-out pathway could best apply to stable patients with ADD-RS = 1 owing to clinical manifestations providing per se higher specificity (i.e., pulse deficit, neurologic deficit, aortic valve insufficiency). 42 Caution is needed in patients with hypotension, which also potentially defines clinical instability and might prompt toward a fast track for advanced imaging irrespective of DD test results. However, in clinical practice, most cases with ADD-RS = 1 will be driven by pain features (severe, sudden, ripping pain), providing higher sensitivity but lower specificity.…”

Section: Discussionmentioning

confidence: 99%

Systematic Review of Aortic Dissection Detection Risk Score Plus D‐dimer for Diagnostic Rule‐out Of Suspected Acute Aortic Syndromes

Bima

Pivetta

Nazerian

et al. 2020

Academic Emergency Medicine

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Objectives: In patients at low clinical probability of acute aortic syndromes (AASs), decision on advanced aortic imaging is cumbersome. Integration of the aortic dissection detection risk score (ADD-RS) with D-dimer (DD) provides a potential pipeline for standardized diagnostic rule-out. We systematically reviewed and summarized supporting data. Methods: Cross-sectional studies assessing integration of ADD-RS with DD for diagnosis of AASs were identified on MEDLINE, EMBASE and Web Of Science databases. Two reviewers independently screened articles, assessed quality, and extracted data. The quality of design and reporting was evaluated with the QUADAS-2 and STARD tools. Individual patient data were obtained, to allow analysis of both conventional (500 ng/mL) and age-adjusted (DD age-adj) DD cutoffs. Data were summarized for four diagnostic strategies combining ADD-RS = 0 or ≤ 1, with DD < 500 ng/mL or < DD age-adj. The statistical heterogeneity of the diagnostic variables was estimated with Higgins' I 2. Pooled values were calculated for variables showing nonsignificant heterogeneity. Results: After screening of 680 studies, four articles (including a total of 3,804 patients) met inclusion criteria. One prospective study provided a low risk of bias/applicability concerns, while methodologic limitations were found in the other three retrospective studies. Statistical heterogeneity was negligible for sensitivity and negative likelihood ratio (LR) values and significant for specificity and positive LR values of all diagnostic strategies. Pooled sensitivity was 99.

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Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta‐analysis

Cited by 50 publications

References 39 publications

Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department

Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department

Integrated Use of Conventional Chest Radiography Cannot Rule Out Acute Aortic Syndromes in Emergency Department Patients at Low Clinical Probability

Systematic Review of Aortic Dissection Detection Risk Score Plus D‐dimer for Diagnostic Rule‐out Of Suspected Acute Aortic Syndromes

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