The EM Cases Team is very excited to bring you not only a new format for the Journal Jam podcast but a new member of the team, Dr. Rory Spiegel, aka @EMNerd_ an Emergency Medicine physician from The University Maryland Medical Center in Baltimore, the founder of the EM Nerd blog and the co-host of the Annals of EM podcast. The new format sees Justin Morgenstern, Teresa Chan, Rory Spiegel and Anton Helman doing deep dives into the world’s literature on specific practical questions while highlighting some important evidence-based medicine concepts. The question we ask in this Journal Jam podcast: Is there a role for D-dimer testing in the workup of aortic dissection in the ED?
The Case for this Journal Jam on the role of D-dimer in the Workup of Aortic Dissection
A 54 year-old man with a history of hypertension and smoking comes in to your ED with 2 hours of acute onset, sharp non-pleuritic 8/10 constant epigastric that radiates to both shoulders.
He vomited once but has no other associated symptoms.
His vitals are normal except for a slightly elevated BP, he has no pulse deficit or aortic murmur, abdomen is benign, his ECG shows non-specific T-wave changes and his CXR is normal.
A repeat ECG is unchanged and his first troponin, lipase and liver enzymes come back negative.
Could the patient in this case be suffering from an aortic dissection?
Does he require a CT aortogram?
Is there a role for D-dimer testing in the workup of aortic dissection in the ED?
We asked ourselves this last question when we came across a review by Asha in the Annals of Emergency Medicine last year. It claimed that D-dimer has a 98% sensitivity for aortic dissection and that it might be useful to rule out dissection in low risk patients.
That’s exciting: A simple blood test to rule out a deadly disease.
But is it too good to be true? Listen to the podcast to find out…
Drs. Helman, Spiegel, Morgenstern and Chan have no conflicts of interest to declare.
Asha SE, Miers JW. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection. Ann Emerg Med. 2015 Oct;66(4):368-78.
Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation. 2011;123(20):2213-8.
Suzuki T, Distante A, Zizza A, et al; IRAD-Bio Investigators. Diagnosis of acute aortic dissection by D-dimer: the International Registry of Acute Aortic Dissection Substudy on Biomarkers (IRAD-Bio) experience. Circulation. 2009 May 26;119(20):2702-7.
Nazerian P, Morello F, Vanni S, Bono A, Castelli M, Forno D, Gigli C, Soardo F, Carbone F, Lupia E, Grifoni S. Combined use of aortic dissection detection risk score and D-dimer in the diagnostic workup of suspected acute aortic dissection. Int J Cardiol. 2014 Jul 15;175(1):78-82.
Gorla R, Erbel R, Kahlert P, Tsagakis K, Jakob H, Mahabadi AA, Schlosser T, Eggebrecht H, Bossone E, Jánosi RA. Accuracy of a diagnostic strategy combining aortic dissection detection risk score and D-dimer levels in patients with suspected acute aortic syndrome. Eur Heart J Acute Cardiovasc Care. 2015 Jul 16.
Xue C, Li Y. Value of d-dimers in patients with acute aortic dissection. J Nanjing Med University. 2007;21:86-88.
Akutsu K, Sato N, Yamamoto T, et al. A rapid bedside D-dimer assay (cardiac D-dimer) for screening of clinically suspected acute aortic dissection. Circ J. 2005;69:397-403.
Fan QK, Wang WW, Zhang ZL, et al. Evaluation of D-dimer in the diagnosis of suspected aortic dissection. Clin Chem Lab Med. 2010;48:1733-1737.
Weber T, Högler S, Auer J, et al. D-dimer in acute aortic dissection. Chest. 2003;123(5):1375-8.
Ohlmann P, Faure A, Morel O, et al. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Crit Care Med. 2006;34(5):1358-64.
Paparella D, Malvindi PG, Scrascia G, et al. D-dimers are not always elevated in patients with acute aortic dissection. J Cardiovasc Med (Hagerstown). 2009;10(2):212-4.
Taylor RA, Iyer NS. A decision analysis to determine a testing threshold for computed tomographic angiography and D-dimer in the evaluation of aortic dissection. Am J Emerg Med. 2013;31(7):1047-55.
Tian L, Fan X, Zhu J, Liang Y, Li J, Yang Y. Plasma D-dimer and in-hospital mortality in patients with Stanford type A acute aortic dissection. Blood Coagul Fibrinolysis. 2014;25(2):161-6.
Moysidis T, Lohmann M, Lutkewitz S, Kemmeries G, Kröger K. Cost associated with D-Dimer screening for acute aortic dissection. Adv Ther. 2011;28(11):1038-44.
Hazui H, Fukumoto H, Negoro N, et al. Simple and useful tests for discriminating between acute aortic dissection of the ascending aorta and acute myocardial infarction in the emergency setting. Circ J. 2005;69(6):677-82.
Eggebrecht H, Naber CK, Bruch C, et al. Value of plasma fibrin D-dimers for detection of acute aortic dissection. J Am Coll Cardiol. 2004;44(4):804-9.
Sakamoto K, Yamamoto Y, Okamatsu H, Okabe M. D-dimer is helpful for differentiating acute aortic dissection and acute pulmonary embolism from acute myocardial infarction. Hellenic J Cardiol. 2011;52(2):123-7.
Perez A, Abbet P, Drescher MJ. D-dimers in the emergency department evaluation of aortic dissection. Academic emergency medicine. 2004.
Paparella D, Malvindi PG, Scrascia G. D-dimers are not always elevated in patients with acute aortic dissection. Journal of cardiovascular medicine. 10(2):212-4. 2009.
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.