The December 2021 issue of Emergency Medicine Practice focused on Thoracic Aortic Syndromes. Acute aortic dissection, one of the deadliest conditions we encounter in the emergency department, falls into this category. In the issue, the authors discuss the use of the Aortic Dissection Detection Risk Score (ADD-RS). Specifically, they note:
“The ADD-RS is a set of 12 clinical markers of AoD for low- to moderate-risk patients when AoD is in the differential diagnosis.2,3 The ADD-RS is based on the AHA and the American College of Cardiology (ACC) guidelines released in 2010,1 which were retrospectively validated using the IRAD data from 2011.2,3 In 2018, the authors of the ADvISED trial evaluated ADD-RS with the use of a D-dimer, through a multicenter prospective observational trial. They found an ADD-RS <1 and with a negative D-dimer demonstrated a negative likelihood ratio of 0.02, negative predictive value of 99.7, and a sensitivity of 98.8%.2 (In this study, a negative cutoff of 500 ng/mL was used.) An ADD-RS = 0 was found to have a sensitivity of 99.6%.2 Literature suggests that the application of this rule decreases unnecessary CT aortograms for suspected AoD.2 In 2019, chest x-ray was added to the clinical scoring tool, though it did not improve performance, and it illustrated insufficient sensitivity for ruling out the disease.4
Although useful, the ADD-RS clinical tool has not been prospectively externally validated. Additionally, the tool incorporates the laboratory evaluation of D-dimer and should be used only to risk-stratify those who have a higher likelihood of AoD, as its accuracy as a “rule-out” tool is insufficient until further evaluation and validation occurs.2 Lastly, neither existing risk-stratification tools nor individual laboratory studies (such as a D-dimer) should be used alone in making clinic decisions.”
The score places patient into low risk (0), Intermediate risk (1) or high risk (2-3 points) with recommendations to proceed directly to imaging for those in the high risk category, and expedite imaging if no other immediate cause of symptoms is identified for those in the intermediate risk category.
High Risk Conditions | Marfan Syndrome | 1 Point If Any Present |
Family history of aortic dissection | ||
Known aortic valve disease | ||
Recent aortic manipulation | ||
Known thoracic aortic aneurysm | ||
High Risk Pain Features (Chest, back, or abdominal pain described as) | Abrupt in onset | 1 Point If Any Present |
Severe in intensity | ||
Ripping or tearing | ||
High Risk Exam Features | Evidence of perfusion deficit | 1 Point If Any Present |
Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain) | ||
Hypotension or shock state |
For further discussion of the score and acute aortic syndromes:
- Thoracic Aortic Syndromes in The Emergency Department: Recognition and Management
- EMplify Podcast: Thoracic Aortic Syndromes – An Interview with Dr. Hackett. (Apple , Google, Spotify )
References
- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/ AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv. 2010;76(2):E43-86. (AHA guideline) PubMedDirect Link
- Nazerian P, Mueller C, Soeiro AM, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED Prospective Multicenter Study. Circulation. 2018;137(3):250-258. (Prospective; 1850 patients) PubMed
- 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):2213-2218. (IRAD registry; 2538 patients) DOI: 10.1161/CIRCULATIONAHA.110.988568 PubMed
- Nazerian P, Pivetta E, ADvISED Investigators, et al. Integrated use of conventional chest radiography cannot rule out acute aortic syndromes in emergency department patients at low clinical probability. Acad Emerg Med. 2019;26(11):1255-1265. (Secondary analysis of ADvISED study data; 1030 patients) PubMed
- Diercks DB, Promes SB, Schuur JD, et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015;65(1):32-42.e12. PubMed Direct Link
- Hackett A, Stuart J, Robinson DL. Thoracic aortic syndromes in the emergency department: recognition and management. Emerg Med Pract. 2021 Dec;23(12):1-28. Epub 2021 Dec 1. PMID: 34787992.
Last Updated on January 24, 2023
