The aortic dissection detection risk score (ADD-RS), alone or in combination with D-dimer, was found to exclude acute aortic syndrome with high sensitivity, according to the results of a systematic review and meta-analysis published in European Heart Journal: Acute Cardiovascular Care.
The researchers performed a literature search of the MEDLINE, Embase, and Cochrane Controlled Register of Trials online databases from inception through December 2018 for studies in which the diagnostic accuracy of ADD-RS was compared with that of aortic imaging. Of the 739 articles identified, 9 studies were included in the analysis, including 8 retrospective studies and 1 conducted in the prehospital setting.
The pooled population included 26,598 patients who were diagnosed with ADD-RS alone, with 1178 cases of acute aortic syndrome, and 3421 patients diagnosed with ADD-RS in combination with D-dimer, with 664 cases of acute aortic syndrome.
The quality of studies was assessed and the majority were found to have low or unclear risk for bias. Four studies were found to have a high risk for bias with regard to patient selection. All studies were deemed of moderate or higher methodological quality.
For these studies, the sensitivity of ADD-RS alone ranged from 0.87 to 1.00 at ADD-RS ≥1, and from 0.31 to 0.92 at ADD-RS ≥2. The pooled sensitivity of ADD-RS alone was 0.94 (95% CI, 0.90-0.96) at ADD-RS ≥1, and 0.46 (95% CI, 0.34-0.59) at ADD-RS ≥2. The sensitivity of ADD-RS with D-dimer was 1.00 (95% CI, 0.99-1.00) at ADD-RS ≥1 and 0.99 (95% CI, 0.97-1.00) at ADD-RS ≥2. Assuming a 5% prevalence of acute aortic syndrome, ADD-RS alone had a failure rate of 0.8% at ADD-RS ≥1 and 3.0% at ADD-RS ≥2 (ie, 1 missed case per 125 and 33 patients, respectively). The efficiency was 38.3% at ADD-RS ≥1 and 88.8% at ≥2. The failure rate was reduced with the addition of D-dimer, to 0.05% at ADD-RS ≥1 and 0.1% at ADD-RS ≥2 (ie, 1 missed case per 2000 and 1000 patients, respectively). If a higher prevalence of acute aortic syndrome (20%) was assumed, the failure rate was higher and the efficiency was lower for each test, but similar trends were observed.
The generalizability of results may be limited as the majority of patients included in the studies were from European or Asian countries.
“ADD-RS alone or in combination with D-dimer can be a useful rule-out test for [acute aortic syndrome]. The optimal threshold may depend on prevalence, setting, and patient or clinician preference,” the study authors concluded. “Physicians should select a strategy using ADD-RS based on their clinical setting.”
Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection detection risk score alone or with D-dimer: A systematic review and meta-analysis [published online January 23, 2020]. Eur Heart J Acute Cardiovasc Care. doi:10.1177/2048872620901831