Evaluating the use of D-Dimers in the use of Thoracic Aortic Aneurysm rule-out in Emergency department attenders
Date First Published:
November 2, 2016
Last Updated:
December 6, 2016
Report by:
Dr Jonathan Sunkersing, Academic Clinical Fellow (Royal Berkshire Hospital)
Search checked by:
Dr Jonathan Sunkersing, Royal Berkshire Hospital
Three-Part Question:
In [emergency admissions with chest pain], can a [D-dimer test] be used to [rule out Thoracic Aortic Aneurysm]?
Clinical Scenario:
A 53 year old man attends the emergency department with a 2 hour history of chest pain that may be cardiac. You want to rule out possible acute aortic aneurysm dissection and wonder whether a D-Dimer level can help do this
Search Strategy:
Medline, Cochrane and EMBASE
Search Details:
MEDLINE
(exp AORTIC ANEURYSM, THORACIC/ OR "aortic dissection*".ti,ab OR (thora* adj2 "aortic aneurysm*").ti,ab OR (thora* adj2 "aorta aneurysm*").ti,ab OR (chest* adj2 "aortic aneurysm*").ti,ab OR (chest* adj2 "aortic aneurysm*").ti,ab OR "aortic dissection*".ti,ab OR ANEURYSM, DISSECTING/ OR "dissecting aortic aneurysm*".ti,ab OR "dissecting aorta aneurysm*".ti,ab) AND ( "d dimer".ti,ab OR ddimer.ti,ab OR exp FIBRIN FIBRINOGEN DEGRADATION PRODUCTS/) AND (exp TOMOGRAPHY, X-RAY COMPUTED/ OR "CT scan*".ti,ab OR "computed tomograph*".ti,ab)
EMBASE
(exp THORACIC AORTA ANEURYSM/ OR exp DISSECTING ANEURYSM/ OR (thora* adj2 "aortic aneurysm*").ti,ab OR (chest* adj2 "aortic aneurysm*").ti,ab OR "aortic dissection*".ti,ab OR "dissecting aortic aneurysm*".ti,ab OR (thora* adj2 "aorta aneurysm*").ti,ab OR "dissecting aorta aneurysm*".ti,ab OR "aorta dissection".ti,ab) AND ("d dimer".ti,ab OR ddimer.ti,ab OR exp D DIMER/) AND ( EXP COMPUTER ASSISTED TOMOGRAPHY/ OR "CT scan*".ti,ab OR "computed tomograph*")
[Limit to: English Language and Publication Year 2006-2016]
(exp AORTIC ANEURYSM, THORACIC/ OR "aortic dissection*".ti,ab OR (thora* adj2 "aortic aneurysm*").ti,ab OR (thora* adj2 "aorta aneurysm*").ti,ab OR (chest* adj2 "aortic aneurysm*").ti,ab OR (chest* adj2 "aortic aneurysm*").ti,ab OR "aortic dissection*".ti,ab OR ANEURYSM, DISSECTING/ OR "dissecting aortic aneurysm*".ti,ab OR "dissecting aorta aneurysm*".ti,ab) AND ( "d dimer".ti,ab OR ddimer.ti,ab OR exp FIBRIN FIBRINOGEN DEGRADATION PRODUCTS/) AND (exp TOMOGRAPHY, X-RAY COMPUTED/ OR "CT scan*".ti,ab OR "computed tomograph*".ti,ab)
EMBASE
(exp THORACIC AORTA ANEURYSM/ OR exp DISSECTING ANEURYSM/ OR (thora* adj2 "aortic aneurysm*").ti,ab OR (chest* adj2 "aortic aneurysm*").ti,ab OR "aortic dissection*".ti,ab OR "dissecting aortic aneurysm*".ti,ab OR (thora* adj2 "aorta aneurysm*").ti,ab OR "dissecting aorta aneurysm*".ti,ab OR "aorta dissection".ti,ab) AND ("d dimer".ti,ab OR ddimer.ti,ab OR exp D DIMER/) AND ( EXP COMPUTER ASSISTED TOMOGRAPHY/ OR "CT scan*".ti,ab OR "computed tomograph*")
[Limit to: English Language and Publication Year 2006-2016]
Outcome:
151 papers of which 4 were of sufficient quality. Results already reviewed in these meta-analyses were not presented below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Overutilization of computed tomography angiography for acute aortic dissection: Identifying additional need for a reliable screening biomarker. Wilson S, Kinni H, Smoot T et al 2016 USA | 220 patients (average age 56) | Retrospective cohort study of all patients who had a D-Dimer and CTA performed specifically for acute aortic dissection. | Positive d-dimer in 60.0% cases. Positive D-Dimer carried a sensitivity of 100% (95% CI 15.8-100%) and specificity of 40.4% (95% CI 33.8-47.2%) | Retrospective analysis | |
| Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects. Watanabe H Nobuyuki H, Shibata Y et al. 2016 Japan | 833 subjects and 1994 non-acute aortic dissection | Meta-analysis with bivariate model methodology. 22 studies. 12 included in analysis | Based on a cutoff value of 500 ng/ml, sensitivity was 0.952 (95% CI 0.901-0.978) and specificity was 0.079 (95% CI 0.036-0.172) D-dimer <500 ng/ml largely decreases possibility of acute aortic dissection. | Based on studies that used univariate analysis and had a high risk of bias. | |
| Negative D-dimer test for acute aortic dissection. Satoh Y, Suzuki M, Shiroshita-Takeshita A et al. 2011 Japan | 49 patients | Single centre prospective observational study | 10% of patients with acute aortic dissection in emergency settings showed negative D-Dimer test results. | Single centre, observational study | |
| Improved Rule-Out Diagnostic Gain with a Combined Aortic Dissection Detection Risk Score and D-Dimer Bayesian Decision Support Scheme. Baez A, Cochon L. 2016 UK | 349 patients | Meta-analysis of 11 studies - multi centre, multinational. | An aortic dissection detection risk score combined with D-dimer testing is suitable for ruling out aortic dissection in low-intermediate risk patients. Negative likelihood ratio of 0.24% for low risk, 3.4% for intermediate risk and 7.9% for high risk. | Intrinsic weakness of selected studies and hypothetical mathematical model used. No significant difference between D-Dimer testing with CT for the rule out of low risk patients. |
Author Commentary:
The recent meta-analysis by Watanabe is a well written paper that incorporates most of the latest studies looking at the diagnostic accuracy of D-dimer for acute aortic syndrome. They identified 22 papers and used 12 of these which utilised the cutoff value of 500 ng/ml. The authors analyse and critique the key papers they used in the meta-analysis and this is a strength of their publication.
The recent publication by Armado Baez in the Journal of Critical Care, aimed to design a simple, systematic tool for screening patients for aortic dissection utilising D-dimers. Patients are grouped into low, intermediate and high risk. This study was good in showing this score with D-Dimer testing could be used to rule out acute aortic dissection in low risk patients.
The recent publication by Armado Baez in the Journal of Critical Care, aimed to design a simple, systematic tool for screening patients for aortic dissection utilising D-dimers. Patients are grouped into low, intermediate and high risk. This study was good in showing this score with D-Dimer testing could be used to rule out acute aortic dissection in low risk patients.
Bottom Line:
Patients with low clinical probability for acute aortic dissection and a low D-Dimer are unlikely to have an acute aortic dissection.
References:
- Wilson S, Kinni H, Smoot T et al. Overutilization of computed tomography angiography for acute aortic dissection: Identifying additional need for a reliable screening biomarker.
- Watanabe H Nobuyuki H, Shibata Y et al.. Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects.
- Satoh Y, Suzuki M, Shiroshita-Takeshita A et al.. Negative D-dimer test for acute aortic dissection.
- Baez A, Cochon L.. Improved Rule-Out Diagnostic Gain with a Combined Aortic Dissection Detection Risk Score and D-Dimer Bayesian Decision Support Scheme.