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Response by Morello et al to Letters Regarding Article, “Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D–Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study”
2018; Lippincott Williams & Wilkins; Volume: 138; Issue: 4 Linguagem: Inglês
10.1161/circulationaha.118.034861
ISSN1524-4539
AutoresFulvio Morello, Christian Mueller, Alexandre de Matos Soeiro, Bernd A. Leidel, Sibilla Anna Teresa Salvadeo, Peiman Nazerian,
Tópico(s)Hip and Femur Fractures
ResumoHomeCirculationVol. 138, No. 4Response by Morello et al to Letters Regarding Article, "Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D–Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Morello et al to Letters Regarding Article, "Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D–Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study" Fulvio Morello, MD, PhD, Christian Mueller, MD, Alexandre de Matos Soeiro, MD, Bernd A. Leidel, MD, Sibilla Anna Teresa Salvadeo, MD, Peiman Nazerian, MD and For the ADvISED Investigators Fulvio MorelloFulvio Morello S.C.U. Medicina d'Urgenza, A.O.U. Città della Salute e della Scienza, Molinette Hospital, Torino, Italy (F.M.). , Christian MuellerChristian Mueller Cardiovascular Research Institute, University Hospital of Basel, Switzerland (C.M.). , Alexandre de Matos SoeiroAlexandre de Matos Soeiro Emergency Care Unit, Heart Institute, University of São Paulo, Brazil (A.d.M.S.). , Bernd A. LeidelBernd A. Leidel Department of Emergency Medicine, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, Germany (B.A.L.). , Sibilla Anna Teresa SalvadeoSibilla Anna Teresa Salvadeo Department of Emergency Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.A.T.S.). , Peiman NazerianPeiman Nazerian Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy (P.N.). and For the ADvISED Investigators Originally published23 Jul 2018https://doi.org/10.1161/CIRCULATIONAHA.118.034861Circulation. 2018;138:448–449In Response:We agree with Roncon et al that ECG remains crucial in the diagnostic evaluation of patients with suspected acute aortic syndromes (AAS) even in the era of biomarker-assisted algorithms. In AAS, ECG findings are commonly abnormal but also highly unspecific, even more than in pulmonary embolism. Ischemic ECG alterations are red flags for critical patients and may expedite transport and medical evaluation, but they also increase the risks of misdiagnosis and administration of antiplatelet and anticoagulant agents.1,2 Therefore, it is crucial that ECG interpretation is 3-dimensionally integrated with demographic, history, and diagnostic data, including biomarkers such as troponin and D-dimer. In the ADvISED study, an ECG was performed in all patients and examined by the treating physicians during the index visit.3 Hence, ECG likely contributed to the clinical gestalt when defining a suspicion of AAS and outlining the differential diagnosis. For practical reasons, however, ECG traces and data were not systematically recorded. Of note, a troponin test was obtained in 1782 (96.4%) study patients, indicating that acute coronary syndromes represented a key concern.As outlined by Wang et al, low diagnostic specificity represents a well-known pitfall of D-dimer (DD), because several conditions beyond AAS engage fibrinolysis and therefore yield falsely positive results. These include thromboembolism, sepsis, cancer, smoking, and coagulopathy. In the ADvISED study, data on smoking and active cancer were recorded in 1844 (99.8%) patients. The overall sensitivity and specificity of DD for AAS were 96.7% (95% CI, 93.6–98.3) and 64% (95% CI, 61.7–66.3), respectively, in line with previous data.3,4 In patients with history of smoking or cancer (n=689), the sensitivity and specificity of DD for AAS were 97.1% (95% CI, 89.9–99.2) and 66.5% (95% CI, 62.7–70.1), respectively. These data indicate that DD could be useful for rule-out of AAS also in patients with these comorbidities.DD levels also increase with aging. In suspected pulmonary embolism, use of an age-adjusted DD (DDadj) cutoff for diagnostic rule-out has been shown to increase specificity and efficiency without affecting sensitivity.5 As discussed in the Editorial, a single cutoff for pulmonary embolism and AAS may be practical, as these conditions are key concerns in patients with truncal pain and both require computed tomography angiography for conclusive diagnosis.6 Kotani et al have previously reported in a retrospective study that also in AAS, DDadj may increase specificity with a small trade-off in sensitivity, as compared with a single 500 ng/mL cutoff.7We took advantage of the ADvISED data to evaluate the performance of a DDadj-based approach. The DDadj cutoff was calculated as age (years) × 10 ng/mL (minimum 500 ng/mL). There were 1148 (62.1%) patients presenting a negative DDadj (DDadj−), including 111 (6%) patients testing positive with the 500 ng/mL cutoff. Patient classification based on DDadj differed from the 500 ng/mL classification (P<0.001). For AAS, DDadj had an overall sensitivity and specificity of 95.4% (95% CI, 92–97.4) and 70.8% (95% CI, 68.5–72.9), respectively. Patients with AAS and DDadj− were 11 (4.6%), as compared with 8 (3.3%) with the single 500 ng/mL cutoff. The additional false-negative patients with DDadj were affected by 1 type B aortic dissection, 1 intramural hematoma, and 1 penetrating ulcer.Within aortic dissection detection risk score (ADD–RS)=0, 318 individuals had DDadj−, including 1 with AAS. This yielded for the ADD–RS=0/DDadj− strategy a failure rate of 0.31% (95% CI, 0.05–1.75). The efficiency in ruling-out AAS was 17.2% (95% CI, 15.5–19), corresponding to 1 in 6 patients. For the ADD–RS=0/DD<500 ng/mL strategy, the failure rate was 0.34% (95% CI, 0.06–1.9) and the efficiency was 15.9% (95% CI, 14.3–17.6).Within ADD–RS≤1, 1017 individuals had DDadj−, including 5 with AAS. This yielded for the ADD–RS≤1/DDadj− strategy a failure rate of 0.49% (95% CI, 0.21–1.14), corresponding to 1 missed case in 203 patients. The efficiency in ruling out AAS was 55% (95% CI, 52.7–57.2), corresponding to 5 in 9 patients. For the ADD–RS≤1/DD<500 ng/mL strategy, the failure rate was 0.32% (95% CI, 0.11–0.94) and the efficiency was 49.9% (95% CI, 47.7–52.2). Overall, these data indicate that DDadj may be considered in diagnostic algorithms of AAS to increase rule-out efficiency with a minimum trade-off in sensitivity.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Costin NI, Korach A, Loor G, Peterson MD, Desai ND, Trimarchi S, de Vincentiis C, Ota T, Reece TB, Sundt TM, Patel HJ, Chen EP, Montgomery DG, Nienaber CA, Isselbacher EM, Eagle KA, Gleason TG. Patients with type A acute aortic dissection presenting with an abnormal electrocardiogram.Ann Thorac Surg. 2018; 105:92–99. doi: 10.1016/j.athoracsur.2017.06.063.CrossrefMedlineGoogle Scholar2. Hansen MS, Nogareda GJ, Hutchison SJ. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection.Am J Cardiol. 2007; 99:852–856. doi: 10.1016/j.amjcard.2006.10.055.CrossrefMedlineGoogle Scholar3. Nazerian P, Mueller C, Soeiro AM, Leidel BA, Salvadeo SAT, Giachino F, Vanni S, Grimm K, Oliveira MT, Pivetta E, Lupia E, Grifoni S, Morello F; ADvISED Investigators. Diagnostic accuracy of the aortic dissection detection risk score plus d-dimer for acute aortic syndromes: the ADvISED prospective multicenter study.Circulation. 2018; 137:250–258. doi: 10.1161/CIRCULATIONAHA.117.029457.LinkGoogle Scholar4. Watanabe H, Horita N, Shibata Y, Minegishi S, Ota E, Kaneko T. Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects.Sci Rep. 2016; 6:26893. doi: 10.1038/srep26893.CrossrefMedlineGoogle Scholar5. Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, Rutschmann OT, Sanchez O, Jaffrelot M, Trinh-Duc A, Le Gall C, Moustafa F, Principe A, Van Houten AA, Ten Wolde M, Douma RA, Hazelaar G, Erkens PM, Van Kralingen KW, Grootenboers MJ, Durian MF, Cheung YW, Meyer G, Bounameaux H, Huisman MV, Kamphuisen PW, Le Gal G. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.JAMA. 2014; 311:1117–1124. doi: 10.1001/jama.2014.2135.CrossrefMedlineGoogle Scholar6. Suzuki T, Eagle KA. Biomarker-assisted diagnosis of acute aortic dissection.Circulation. 2018; 137:270–272. doi: 10.1161/CIRCULATIONAHA.117.032048.LinkGoogle Scholar7. Kotani Y, Toyofuku M, Tamura T, Shimada K, Matsuura Y, Tawa H, Uchikawa M, Higashi S, Fujimoto J, Yagita K, Sato F, Atagi Y, Hamasaki T, Tsujimoto T, Chishiro T. Validation of the diagnostic utility of D-dimer measurement in patients with acute aortic syndrome.Eur Heart J Acute Cardiovasc Care. 2017; 6:223–231. doi: 10.1177/2048872616652261.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lee D, Kim Y, Kim T, Lee S, Do H, Seo J, Lee J and Lin Y (2022) Age-Adjusted D-Dimer in Ruling Out Acute Aortic Syndrome, Emergency Medicine International, 10.1155/2022/6864756, 2022, (1-6), Online publication date: 5-Feb-2022. Morello F, Bima P, Pivetta E, Santoro M, Catini E, Casanova B, Leidel B, de Matos Soeiro A, Nestelberger T, Mueller C, Grifoni S, Lupia E and Nazerian P (2021) Development and Validation of a Simplified Probability Assessment Score Integrated With Age‐Adjusted d‐Dimer for Diagnosis of Acute Aortic Syndromes, Journal of the American Heart Association, 10:3, Online publication date: 2-Feb-2021. Morello F, Santoro M, Fargion A, Grifoni S and Nazerian P (2020) Diagnosis and management of acute aortic syndromes in the emergency department, Internal and Emergency Medicine, 10.1007/s11739-020-02354-8, 16:1, (171-181), Online publication date: 1-Jan-2021. Bima P, Pivetta E, Nazerian P, Toyofuku M, Gorla R, Bossone E, Erbel R, Lupia E, Morello F and Carpenter C (2020) Systematic Review of Aortic Dissection Detection Risk Score Plus D‐dimer for Diagnostic Rule‐out Of Suspected Acute Aortic Syndromes, Academic Emergency Medicine, 10.1111/acem.13969, 27:10, (1013-1027), Online publication date: 1-Oct-2020. Earl-Royal E, Nguyen P, Alvarez A and Gharahbaghian L (2019) Detection of Type B Aortic Dissection in the Emergency Department with Point-of-Care Ultrasound, Clinical Practice and Cases in Emergency Medicine, 10.5811/cpcem.2019.5.42928, 3:3, (202-207) July 24, 2018Vol 138, Issue 4 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.034861PMID: 30571366 Originally publishedJuly 23, 2018 PDF download Advertisement SubjectsAortic DissectionDiagnostic Testing
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