ED use of D-Dimer in ruling out Thoracic Dissection

Viewer
Transcript

Chad Dunn M.D. EVMS Journal Club 8-26-07

E.D. use of D-Dimer in ruling out Thoracic Dissection PICO In Patients with chest pain or other symptoms concerning for thoracic aortic dissection, does the use of ddimer compared to deferring d-dimer, offer advantages in the detection of thoracic dissection. Clinical scenario A 51 year old male presents to the E.D. with stabbing chest pain. His BP is 190/110. His EKG and CXR are normal, but you wonder if you should do further testing to rule out acute thoracic aortic dissection. Search Strategy Pub Med and Medline (OVID) using the keywords: aortic dissection AND d-dimer Relevant Studies Author, date Akutsu, et al., 2005

Eggebrecht, et al., 2004

Weber, et al., 2003

Weber, et al., 2006

Ohlmann, et al., 2006

Study type Prospective study of pt’s with sudden onset of chest or back pain and no EKG evidence of ischemia. Also looked at whether or not BP could help with predictive value. Prospective study of patients with chest pain

Results 100% sensitivity for d-dimer >0.5 mcg/ml. 54% specificity. 40% of Acute AD pt’s had sbp >/=180 vs. 8% of pt’s without acute AD

Weaknesses 1. N=30 2. Excluded pt’s with EKG evidence of ischemia

Other Used rapid bedside d-dimer

Cutoff of 0.5 mcg/mL had 100% sensitivity and 67% specificity

1. N = 16 2. Only pt’s with chest pain were included in the study

Prospective study of patients with suspected acute AD (10 patients) as well as retrospective study in 14 pt’s with known acute AD Retrospective study on patients with known acute AD Retrospective case-control study looking at pt’s admitted with

100%sensitivity. 68.6% specificity

1.N=24

*Average d-dimer 0.632 in chronic AD and 6.419 in acute AD. *Authors recommendation was to do imaging in high clinical suspicion cases. Mean d-dimer 9.4 (range 0.63-54.7)

Sensitivity of 100%.

1.N=27 2. Retrospective

99% sensitivity using .40 mcg/ml

1. 2.

Retrospective Exluded pt’s who had not already had a

*Also found that level of d-dimer had prognostic significance. *N=94 *1 pt with Acute AD had d-dimer <0.4; 1 pt had d-

confirmed acute AD who had already had ddimer drawn

Hazui, et al., 2005

Hazui, et al., 2006

Perez, et al., 2004

Sbarouni, et al., 2007

Retrospective. Used d-dimer and mediastinum diameter on cxr to differentiate b/t acute MI and acute AD Retrospective. Checked d-dimer immediately after admission in all pt’s with acute AD if within 24 hours of onset of symptoms

Retrospective chart review of pt’s diagnosed with acute AD who had already had ddimer drawn. Retrospective study of known acute AD

d-dimer drawn

Using d-dimer 0.8mcg/ml and mratio of 0.309 found sensitivity of 93.1% for acute AD and 91.8% for acute MI 92% sensitivity with cutoff of 0.4 mcg/ml. False negatives were in younger pt’s with short dissecting length and thrombosed false lumen. Not statistically significant in younger patients. 100% sensitivity for >0.5 mcg/L

1. 2. 3.

94% sensitivity for d-dimer > .7 mcg/ml 59 % specificity

1.N=18 2. Retrospective

dimer of 0.43. Both of these pt’s had intramural hematoma and nonpatent false lumen. *Noted that 27% of Acute AD had normal CXR. Did not mention whether or not these pt’s included the pt’s with neg. d-dimer. *Noted that 38% of acute AD pt’s had d-dimer >12 mcg/ml, so they concluded that severely elevated d-dimer should prompt consideration of thoracic dissection in pt’s with nonevocative symptoms

Retrospective. N=29 Excluded type B dissections

Retrospective

*N=113

1.N=7 2. Retrospective

*had 156 patients with Acute AD in the time period but only 7 pt’s had ddimer level checked. d-dimer cutoff of .7 mcg/ml helped differentiate b/t pt’s w/ chronic

dissection Comments: Total of 9 studies by 7 different authors with a total N of 358. All but 3 of the studies are retrospective. Sensitivity ranged from 92% to 100% with varying d-dimer cutoff level. Specificity ranged from 5468.6%. Small N is likely due to the infrequency of pt’s with acute AD. Clinical bottom line: The combination of a negative cxr and negative d-dimer with a cutoff of 0.4 to 0.5 mcg/ml can rule out acute aortic dissection in low to moderate risk patients. In high risk patients imaging is still necessary but a d-dimer level can help in establishing prognosis.

References: 1. Akutsa, K, Sato, N, Yamamoto, T, Morita, N, Takagi, H, Fujita, N, Tanaka, K, Takano, T. A Rapid Bedside D-dimer Assay (Cardiac D-Dimer) for Screening of Clinically Suspected Acute Aortic Dissection. Circulation Journal 2005; (69): 397-403. 2. Eggebrecht, H, Naber, C, Bruch, C, Kroger, K, von Birgelen, C, Schmermund, A, Wichert, M, Bartel, T, Mann, K and Erbel, R. Value of plasma fibrin D-dimers for detection of acute aortic dissection. Journal of American College of Cardiology 2004; 44; 804-809. 3. Weber, T, Hogler, S, Auer, J, Berent, R, Lassnig, E, Kvas, E and Eber, B. D-dimer in Acute Aortic Dissection. Chest 2003; 123; 1375-1378. 4. Weber, T, Rammer, M, Auer, J, Maurer, E, Aspock, G, Eber, B. Plasma concentrations of D-dimer predict mortality in acute type A aortic dissection. Heart 2006; 92; 836-837. 5. Ohlmann, P, Faure, A, Morel, O, Petit, H, Kabbaj, H, Meyer, N, Cheneau, E, Jesel, L, Epailly, E, Desprez, D, Grunebaum, L, Schneider, F, Roul, G, Mazzucotteli, J, Eisenmann, B and Bareiss, P. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Critical Care Medicine. 2006; 34: 1358-1364. 6. Hazui , H, Fukumoto, H,, , Negoro, N, Hoshiga, M, Muraoka, H, Nishimoto, M, Morita, H. and Hanafusa, T. Simple and Useful Tests for Discriminating Between Acute Aortic Dissection of the Ascending Aorta and Acute Myocardial Infarction in the Emergency Setting. Circulation Journal 2005; 69: 677-682. 7. Hazui, H, Nishimoto, M, Hoshiga, M, Negoro, N, Muraoka, H, Murai, M, Ohishi, Y, Fukumoto, H, Morita, H. Young Adult Patients With Short Dissection Length and Thrombosed False Lumen Without Ulcer-Like Projections are Liable to Have False-Negative Results of D-Dimer Testing for Acute Aortic Dissection Based on a Study of 113 Cases. Circulation Journal. 2006; 70: 1598-1601. 8. Perez, A, Abbet, P, Drescher, M. D-dimers in the Emergency Department Evaluation of Aortic Dissection. Academic Emergency Medicine 2004; 11(4):397-400. 9. Sbarouni, E, Panagiota, G, Aikaterini, M, Geroulanos, S, Kremastinos, D. D-dimer and BNP levels in acute aortic dissection. International Journal of Cardiology. 2007 (Article in press).