D-dimer and Point-of-Care Ultrasound to Rule Out Aortic Dissection in Low-Risk Patients
Date First Published:
November 29, 2025
Last Updated:
November 29, 2025
Report by:
Raydeer Piromari DO, Lindsey Rauch MD, Senior EM resident, EM Faculty (Corewell Health/Michigan State University Emergency Medicine Residency Program, Grand Rapids)
Search checked by:
Jeffrey Jones, MD, Research Director
Three-Part Question:
in [emergency department patients with a low suspicion for aortic dissection (aortic dissection detection risk score (ADD-RS) ≤1) what is the [diagnostic accuracy of D-dimer and point-of-care ultrasound (POCUS)] as a [screening test for the diagnosis of aortic dissection]?
Clinical Scenario:
A 50-year-old female with stage 4 chronic kidney disease (CKD) presents to the emergency department with shortness of breath and chest pain. Workup shows an ECG with a normal sinus rhythm and non-specific ST-T wave changes. She is at low risk for aortic dissection (ADD-RS = 1), and her D-dimer was normal (400 ng/mL). Given her CKD, you wonder if there is a way to rule out an acute aortic dissection without having to give a contrast load for a computed tomography (CT) angiogram. Will a normal D-dimer and POCUS rule out acute aortic dissection with certainty?
Search Strategy:
Medline 1966-09/25 using PubMed, Cochrane Library (2025), and Embase
Search Details:
[(Aortic Diseases/diagnostic imaging [MeSH] OR Aortic Diseases/diagnosis [MeSH]) AND (Fibrin fibrinogen degradation products/analysis [MAJR]) AND (ultrasonography [MAJR])]. Limit to adults and English language.
Outcome:
Four studies were identified, one addressed the clinical question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study Morello F, Bima P, Castelli M, et al, October 2024 Italy/Brazil/Germany/Switzerland/Malaysia/Austria | 1979 adults with at least one AAS-compatible symptom (thoracic/back/abdominal pain, syncope, organ perfusion deficit, i. e. focal neurologic deficit, limb ischemia) lasting for up to 14 days, and AAS considered a meaningful diagnostic concern. | Prospective study to assess the safety and efficiency of a diagnostic protocol integrating clinical data with point-of care ultrasound (POCUS) and D-dimer (single/age-adjusted cutoff), to select patients for AAI. | Assess protocol safety and efficiency, and to estimate the performance of an age-adjusted D-dimer test interpretation, with a working hypothesis of increased efficiency. | POCUS led to net reclassification improvement of 20 % (P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). The 30-day incidence of AAS was 0 % (95 % CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 %. | Since POCUS has lower accuracy for tears/IMH/PAU and type B forms, misdiagnosis risk could be higher in patients with these subtypes. The study also did not evaluate the potentially negative impact of the protocol on detection of other diseases, both aortic and non-aortic. Results were mostly obtained in centers expert in POCUS and AAS limiting generalizability. Protocol adherence was suboptimal. |
Author Commentary:
This study highlights the potential use in using history, POCUS, and d dimer to rule out AAS and also to aid in the decision making process on the imaging modality of choice. With using their proposed algorithm, they were able to lower the use of advanced imaging in 41% of patients. This intern lowers costs, increases ED efficacy, and most importantly lowers the potential risk of a contrasted study.
Bottom Line:
Diagnostic strategy using POCUS-integrated PTP plus D-dimer safely ruled out AAS. This also lowered the use of advanced imagining on 41% of patients
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Morello F, Bima P, Castelli M, et al,. Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study