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This case illustrates that d-dimer is elevated in patients with acute aortic dissection. A 49-year-old woman presented with central, crushing chest pain exacerbated on inspiration. The chest pain was associated with right-leg numbness and pain, although peripheral pulses and blood pressures were normal. Routine bloods demonstrated an elevated d-dim...
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Acute aortic dissection is an uncommon disorder which can have fatal results in the event of treatment delay or misdiagnosis. This case examines a 77-year-old woman presenting with chest pain relieved by nitroglycerin. She was referred to the emergency room with clinical suspicion of acute coronary syndrome (ACS). However, she was later diagnosed w...
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Citations
... Additionally, the application of D-dimer extends as an index of hypercoagulability, particularly in the diagnosis and monitoring of disseminated intravascular coagulation (DIC) [1]. Recently, its potential diagnostic utility has expanded to coronary diseases and acute aortic dissection [1,4,5], as well as stratification of pulmonary damage [6]. The experience of the pandemic has highlighted the significance of the coagulative profile in patients with COVID, particularly with regard to D-Dimer results. ...
Introduction
This observational study conducted across seven emergency care units compares the efficacy of four D‐dimer detection methods, namely HemosIL D‐dimer HS (HS), HemosIL D‐dimer HS‐500 (HS‐500), VIDAS D‐dimer (VIDAS), and HemosIL AcuStar D‐dimer (ACUSTAR). The primary focus is on patients with a clinical suspicion of deep venous thrombosis (DVT) or pulmonary embolism (PE).
Methods
A total of 149 samples were collected from patients with suspected DVT or PE. The confirmation of DVT/PE was based on calf ultrasound or computed tomography‐Angiography. Direct comparisons were made between the different detection methods, considering both their analytical performance and clinical utility. Additionally, the impact of an age‐adjusted cut‐off on the diagnostic accuracy of each method was assessed.
Results
The results revealed comparable negative predictive value, sensitivity, and specificity across the methods, with a notable exception of increased specificity for HS compared with HS‐500 (50.8% vs. 41.5%, p = 0.03). Further analysis incorporating an age‐adjusted cut‐off demonstrated a significant improvement in specificity for HS. When using the age‐adjusted cut‐off, HS exhibited a substantial increase in specificity compared with HS‐500 (63.1% vs. 49.2%, p = 0.004) and demonstrated significantly higher specificity compared with VIDAS (63.1% vs. 53.8%, p = 0.04).
Conclusion
The study emphasizes the nonuniversal effect of an age‐adjusted cut‐off and discusses the potential necessity for different cut‐off values, particularly in the case of HS‐500. These findings contribute to the understanding of D‐dimer detection methods in the context of DVT and PE, providing insights into their relative performances and the potential optimization through age‐adjusted cut‐offs.
... Notably, one study noted that since D-dimer has a high false positive rate as a biomarker for AAS, patients with D-dimer > 500 ng/mL should be diagnosed in combination with other tools rather than D-dimer alone [19]. Another study suggests a D-dimer cutoff value of 1600 ng/mL for AAS, which generates a high positive likelihood ratio [20]. Thus, integrating the abovementioned evidence, a combination of ADD-RS with D-dimer might be an outstanding choice for assisting AAS diagnosis. ...
This study aimed to assess the diagnostic performance of the aortic dissection detection risk score (ADD-RS) plus D-dimer for acute aortic syndrome (AAS) in Chinese patients. Two hundred and sixty-two and 200 patients with suspected AAS symptoms were enrolled as exploration cohort and validation cohort, respectively. In exploration cohort, ADD-RS plus D-dimer (AUC = 0.929, 95%CI: 0.887–0.971) presented a better diagnostic value for AAS than ADD-RS or D-dimer alone. Meanwhile, ADD-RS > 1 and D-dimer > 2000 ng/mL were the optimal thresholds. Then, a diagnostic model integrating ADD-RS > 1 plus D-dimer > 2000 ng/mL was established, presenting sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 92.5%, 70.3%, 34.9%, and 98.2%, respectively. In validation cohort, the established diagnostic model exhibited a sensitivity, specificity, PPV, and NPV of 93.1%, 70.2%, 34.6%, and 98.4%, respectively, for diagnosing AAS. Summarily, ADD-RS > 1 and D-dimer > 2000 ng/mL are optimal thresholds for diagnosing AAS in the Chinese population. However, confirmative MSCT results are necessary.
Graphical Abstract
Acute aortic syndromes (AAS) represent a spectrum of acute aortic disruption characterized by the loss of integrity of the aortic wall with the potential for catastrophic complications. Types of aortic disruption include typical aortic dissection (AoD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU). Imaging tests are sensitive and specific; however, timely diagnosis may be delayed due to the relative rarity of AAS and the variability in presenting syndrome. Classification systems facilitate early decision-making aimed at preventing acute catastrophe particularly for patients presenting with involvement of the ascending aorta (Type A). Surgery is the preferred acute treatment in this setting when feasible. Patients presenting with disruptions isolated to the descending aorta (Type B) have variable outcomes based in part from the presence of subsequent development of complications (e.g., organ or limb malperfusion, aneurysm formation, and rupture), the patency and size of the false lumen, and their co-morbidities. Those without complications generally treated medically. The role for intervention for Type B acute aortic syndromes is evolving as endovascular approaches continue to improve and offer an alternative to surgery. Patients with acute aortic syndromes have very high early risk requiring close observation and intensive medical care. For those that survive the acute period, rates of long-term complications are significant necessitating close follow-up and serial imaging. The optimal care of these complex patients may be optimal when delivered through a multidisciplinary team.
Acute ST segment elevation myocardial infarction (STEMI) is typically associated with acute coronary thrombosis or plaque rupture. Rarely, STEMI can be associated with ascending aortic dissection, which represents the majority of acute aortic syndrome aetiologies and carries dreadful outcomes. Routine cardiac intervention with emergent cardiac catheterisation may lead to a higher mortality rate in this group of patients. We present a case of painless inferior STEMI in the setting of ascending aortic dissection. The patient had an inferior STEMI due to the involvement of the right coronary artery as an extension of the ascending aortic dissection. In this era of protocol-driven practice and the pressure to fulfil quality measures, we aim to alert emergency physicians, cardiologists and interventionalists of the possible presentation of painless ascending aortic dissection as an STEMI. The two pathologies characterise by crucial differences in their initial and ultimate management.
Acute aortic syndromes constitute a spectrum of conditions characterized by disruptions in the integrity of the aortic wall that may lead to potentially catastrophic outcomes. They include classic aortic dissection, intramural hematoma, and penetrating aortic ulcer. Although imaging studies are sensitive and specific, timely diagnosis can be delayed because of variability in presenting symptoms and the relatively low frequency with which acute aortic syndromes are seen in the emergency setting. Traditional classification systems, such as the Stanford system, facilitate early treatment decision-making through recognition of the high risk of death and major complications associated with involvement of the ascending aorta (type A). These patients are treated surgically unless intractable and severe co-morbidities are present. Outcomes with dissections that do not involve the ascending aorta (type B) depend on the presence of acute complications (e.g., malperfusion, early aneurysm formation, leakage), the patency and size of the false lumen, and patient co-morbidities. Patients with uncomplicated type B dissections are initially treated medically. Endovascular techniques have emerged as an alternative to surgery for the management of complicated type B dissections when intervention is necessary. Patients with acute aortic syndromes require aggressive medical care, risk stratification for additional complications and targeted genetic assessment as well as careful long-term monitoring to assess for evolving complications. The optimal care of patients with acute aortic syndrome requires the cooperation of members of an experienced multidisciplinary team both in the acute and chronic setting.
