The acute aortic dissection detection risk score (ADD-RS), used alone or in combination with dimerized plasmin fragment D (D-dimer) was found to rule acute aortic syndrome (AAS) with high sensitivity, according to a systematic review and meta-analysis published in European Heart Journal: Acute Cardiovascular Care.
The investigators searched Cochrane Controlled Register of Trials, Embase, and MEDLINE, up to December 2018 for studies in which the accuracy of ADD-RS was examined. Two authors independently assessed selected studies for eligibility, and examined data on: patient demographics, sample size, study characteristics number of cases and controls, study setting methodological quality, ADD-RS cut-off value, D-dimer cutoff value (if appropriate), types of reference tests, and sensitivity and specificity. Disagreements were resolved by consensus and consultation with a third author. Methodological quality was independently assessed in this same manner.
A total of 9 studies (n=26,598 and n=3421 in which the accuracy of ADD-RS alone or with D-dimer was examined) were identified. The studies had a methodological quality that was moderate or higher, based on the revised Quality Assessment of Diagnostic Accuracy Studies tool.
The reported sensitivity of ADD-RS alone was 0.87 to 1.00 at an ADD-RS threshold ≥1, and 0.31 to 0.92 at ADD-RS ≥2. The reported specificity of ADD-RS alone was 0.09 to 0.83 at ADD-RS ≥1, and 0.67 to 0.99 at ADD-RS ≥2. The reported sensitivity of ADD-RS with D-dimer was 1.00 for ADD-RS ≥1. A meta-analysis including 8 studies showed a higher pooled sensitivity with an ADD-RS threshold ≥1 vs ≥2, and a lower pooled specificity at an ADD-RS threshold ≥1 vs ≥2. The meta-analysis including 4 studies assessing ADD-RS with D-dimer had a very high pooled sensitivity at ADD-RS tresholds ≥1 and ≥2, but a very low pooled specificity. For ADD-RS alone, the pooled likelihood ratio (LR) from the 8 studies was 0.16 (95% CI, 0.09-0.29) at ADD-RS ≥1, and 0.59 (95% CI, 0.46-0.76) at ADD-RS ≥2. For ADD-RS with D-dimer, the pooled LR from the 4 studies was 0.01 (95% CI, 0.00-0.07) at ADD-RS ≥1, and 0.02 (95% CI, 0.01-0.06) at ADD-RS ≥2.
Assuming a low-prevalence AAS setting (5% pretest probability), failure rate for ADD-RS alone was 0.8% at ADD-RS ≥1 and 3.0% at ADD-RS ≥2; and the efficiency was 38.3% at ADD-RS ≥1 and 88.8% at ADD-RS ≥2. The failure rate of ADD-RS with D-dimer was 0.05% at ADD-RS ≥1 and 0.1% at ADD-RS ≥2, and the efficiency was 14.6% at ADD-RS ≥1 and 33.6% at ADD-RS ≥2. ADD-RS alone had a 3.8% failure rate at ADD-RS ≥1 and a 12.9% rate at ADD-RS ≥2, and an efficiency of 33.3% at ADD-RS ≥1 and 83.3% at ADD-RS ≥2. At the high-prevalence setting, the ADD-RS with D-dimer had a failure rate of 0.2% at ADD-RS ≥1 and 0.5% at ADD-RS ≥2, and an efficiency of 12.3% at ADD-RS ≥1 and 28.4% at ADD-RS ≥2.
”ADD-RS alone or in combination with D-dimer can be a useful rule-out test for AAS. The optimal threshold may depend on prevalence, setting, and patient or clinician preference. Physicians should select a strategy using ADD-RS based on their clinical setting,” concluded the study authors.
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