S.C.U. Medicina d'Urgenza, Molinette Hospital, A.O.U. Città della Salute e della Scienza, Torino, Italy.
Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
Acad Emerg Med. 2020 Oct;27(10):1013-1027. doi: 10.1111/acem.13969. Epub 2020 Apr 21.
In patients at low clinical probability of acute aortic syndromes (AASs), decision on advanced aortic imaging is cumbersome. Integration of the aortic dissection detection risk score (ADD-RS) with D-dimer (DD) provides a potential pipeline for standardized diagnostic rule-out. We systematically reviewed and summarized supporting data.
Cross-sectional studies assessing integration of ADD-RS with DD for diagnosis of AASs were identified on MEDLINE, EMBASE and Web Of Science databases. Two reviewers independently screened articles, assessed quality, and extracted data. The quality of design and reporting was evaluated with the QUADAS-2 and STARD tools. Individual patient data were obtained, to allow analysis of both conventional (500 ng/mL) and age-adjusted (DD ) DD cutoffs. Data were summarized for four diagnostic strategies combining ADD-RS = 0 or ≤ 1, with DD < 500 ng/mL or < DD . The statistical heterogeneity of the diagnostic variables was estimated with Higgins' I . Pooled values were calculated for variables showing nonsignificant heterogeneity.
After screening of 680 studies, four articles (including a total of 3,804 patients) met inclusion criteria. One prospective study provided a low risk of bias/applicability concerns, while methodologic limitations were found in the other three retrospective studies. Statistical heterogeneity was negligible for sensitivity and negative likelihood ratio (LR) values and significant for specificity and positive LR values of all diagnostic strategies. Pooled sensitivity was 99.9% (95% confidence interval [CI] = 99.3% to 100%, I = 0) for ADD-RS = 0 and DD < 500 ng/mL or < DD , 98.9% (95% CI = 97.9% to 99.9%, I = 0) for ADD-RS ≤ 1 and DD < 500 ng/mL, and 97.6% (95% CI = 96.3% to 98.9%, I = 0) for ADD-RS ≤ 1 and DD < DD .
Despite methodologic limitations, integration of ADD-RS = 0 or ≤ 1 with DD < 500 ng/mL shows negligible heterogeneity and consistently high sensitivity across studies, thus supporting reliability for diagnostic rule-out of AASs. Data supporting ADD-RS = 0 plus DD appear preliminary and require further scrutiny.
在临床怀疑急性主动脉综合征（AAS）可能性低的患者中，高级主动脉影像学检查的决策较为复杂。主动脉夹层检测风险评分（ADD-RS）与 D-二聚体（DD）的结合提供了一种标准化诊断排除的潜在途径。我们系统地进行了综述并总结了支持性数据。
在 MEDLINE、EMBASE 和 Web Of Science 数据库中确定了评估 ADD-RS 与 DD 联合用于诊断 AAS 的横断面研究。两名评审员独立筛选文章、评估质量并提取数据。使用 QUADAS-2 和 STARD 工具评估设计和报告的质量。获取了个体患者的数据，以允许分析传统（500ng/mL）和年龄校正（DD）DD 截断值。根据 ADD-RS=0 或≤1 与 DD<500ng/mL 或<DD 的组合，总结了四种诊断策略的数据。使用 Higgins' I 估计诊断变量的统计学异质性。对于显示无显著异质性的变量，计算了汇总值。
在筛选了 680 项研究后，有 4 项研究（共 3804 名患者）符合纳入标准。一项前瞻性研究的偏倚/适用性问题风险较低，而另外三项回顾性研究存在方法学局限性。所有诊断策略的敏感性和阴性似然比（LR）值的统计学异质性可以忽略不计，而特异性和阳性 LR 值的统计学异质性显著。ADD-RS=0 且 DD<500ng/mL 或<DD 的诊断策略的汇总敏感性为 99.9%（95%置信区间 [CI] 99.3% 至 100%，I=0），ADD-RS≤1 且 DD<500ng/mL 的敏感性为 98.9%（95% CI 97.9% 至 99.9%，I=0），而 ADD-RS≤1 且 DD<DD 的敏感性为 97.6%（95% CI 96.3% 至 98.9%，I=0）。
尽管存在方法学局限性，但 ADD-RS=0 或≤1 与 DD<500ng/mL 的结合具有可忽略的异质性，且在各项研究中具有一致的高敏感性，从而支持 AAS 诊断排除的可靠性。支持 ADD-RS=0 加 DD 的数据初步且需要进一步审查。
