The diagnostic value of D-dimer in acute aortic dissection: a meta-analysis

Association of thrombocytopenia and D-dimer elevation with in-hospital mortality in acute aortic dissection

BACKGROUND

Data on the association between the degree of platelet and coagulative-fibrinolytic variables abnormalities and the risk of in-hospital mortality in acute aortic dissection (AAD) are limited.

MATERIALS AND METHODS

This multicentre retrospective cohort study included patients diagnosed with AAD by aortic computed tomographic angiography between 2010 and 2021 in five tertiary hospitals in China. The primary outcome was defined as all-cause mortality during hospitalization. Associations between platelet counts, coagulation-fibrinolytic parameters and all-cause in-hospital mortality were assessed using Cox proportional hazards regression models.

RESULTS

Among the 2567 participants, the median age was 54 years (interquartile range, IQR: 47-63); 531 (20.7%) were female, and the in-hospital mortality rate was 589 (23.0%). The Cox proportional hazards regression model indicated that lower platelet count, prothrombin activity (PTA), and fibrinogen levels and longer prothrombin time (PT) and thrombin time (TT) were linearly positively associated with an increased risk of in-hospital mortality (p < 0.05). A non-linear and positive association was confirmed between D-dimer levels and in-hospital mortality risk (p < 0.05). Additionally, a significant interaction between platelet counts and D-dimer levels was observed (p = 0.029). According to the subgroup analysis, compared to those in the reference group, those with thrombocytopenia (<140 × 109/L) and high D-dimer levels (>14.6 µg/mL) had a 3.59-fold increased risk of in-hospital mortality (HR, 3.59; 95% CI, 2.00-6.42).

CONCLUSIONS

Our analysis revealed associations between changes in platelet count, PT, PTA, TT, fibrinogen and D-dimer levels and outcomes in patients with AAD. Furthermore, the combined effect of thrombocytopenia and high D-dimer levels significantly increased the risk of in-hospital mortality.

A comprehensive exploration of novel biomarkers for the early diagnosis of aortic dissection

Aortic dissection (AD) is a catastrophic life-threatening cardiovascular emergency with a 1-2% per hour mortality rate post-diagnosis, characterized physiologically by the separation of aortic wall layers. AD initially presents as intense pain that can then radiate to the back, arms, neck, or jaw along with neurological deficits like difficulty in speaking, and unilateral weakness in some patients. This spectrum of clinical features associated with AD is often confused with acute myocardial infarction, hence leading to a delay in AD diagnosis. Cardiac and vascular biomarkers are structural proteins and microRNAs circulating in the bloodstream that correlate to tissue damage and their levels become detectable even before symptom onset. Timely diagnosis of AD using biomarkers, in combination with advanced imaging diagnostics, will significantly improve prognosis by allowing earlier vascular interventions. This comprehensive review aims to investigate emerging biomarkers in the diagnosis of AD, as well as provide future directives for creating advanced diagnostic tools and imaging techniques.

A Narrative Review of Biomarkers and Imaging in the Diagnosis of Acute Aortic Syndrome

Acute aortic syndrome (AAS) encompasses a range of life-threatening conditions, including classical dissection, intramural hematoma, and penetrating aortic ulcer. Each of these conditions presents distinct clinical characteristics and carries the potential to progress to rupture. Because AAS can be asymptomatic or present with diverse symptoms, its diagnosis requires clinical evaluation, risk scoring, and biomarkers such as D-dimer (DD), C-reactive protein (CRP), homocysteine, natriuretic peptides (BNP), and imaging modalities like computed tomography (CT), magnetic resonance imaging (MRI), and echocardiography. While this review primarily focuses on widely used and clinically accessible biomarkers and imaging techniques, it also discusses alternative biomarkers proposed for diagnostic use. Although CT remains the gold standard for diagnosis, biomarkers facilitate rapid risk stratification, complementing imaging techniques. Emerging technologies, such as metabolomics, are reshaping diagnostic algorithms. Despite advances in diagnostic methods, challenges such as misdiagnosis and missed diagnoses persist. Ongoing research into novel biomarkers and innovative imaging techniques holds promise for improving diagnostic accuracy and patient outcomes.

Advancements in Serum Biomarkers for Early Diagnosis and Prognostic Assessment of Aortic Dissection

Aortic dissection (AD) is a potentially fatal cardiovascular issue that needs to be diagnosed and treated very away. Although early detection is essential for bettering patient outcomes, there are substantial obstacles with the diagnostic techniques used today. Promising pathways for improving AD prognosis evaluation and early detection are presented by recent developments in serum biomarkers. The most recent research on serum biomarkers for AD is reviewed here, with an emphasis on the prognostic and diagnostic utility of these indicators. A number of biomarkers, including as matrix metalloproteinases, soluble elastin fragments, smooth muscle myosin heavy chain, and D-dimer, have been identified as putative markers of AD. These indicators are indicative of multiple pathophysiological mechanisms associated with AD, including inflammation, extracellular matrix remodeling, and vascular damage. Research has indicated that they are useful in differentiating AD from other acute cardiovascular diseases, facilitating prompt diagnosis and risk assessment.

Bedside-focused transthoracic echocardiography in acute atraumatic thoracic aortic syndrome: a systematic review and meta-analysis of diagnostic accuracy

The objective of this review was to assess the diagnostic accuracy of bedside-focused transthoracic echocardiography (TTE) in acute atraumatic thoracic aortic syndrome in adults. We performed a systematic review and meta-analysis of publications that described the use of bedside-focused TTE on adults presenting to emergency care settings with suspected atraumatic thoracic aortic syndrome. Studies were identified using keyword and MeSH on relevant databases as well as grey literature, followed by abstract screening and study selection by two independent reviewers. Sixteen studies over six decades were included in the meta-analysis ( n  = 4569 patients). The prevalence of type A thoracic aortic dissection was 11% (range 1.4-45.7%) and type B dissection was 7% (range 1.8-30.55%). Pooled sensitivity and specificity for type A dissection (through direct TTE visualisation of an intimal flap) were 89% [95% confidence interval (CI), 82-94%] and 92% (95% CI, 88-95%), respectively. For type B dissection, pooled sensitivity was 65% (95% CI, 45-80%) and specificity was 100% (95% CI, 0.69-100%). Regarding indirect TTE signs, pooled sensitivities and specificities were 64% (5.2-98.2%) and 94% (92-96.1%), respectively for aortic valve regurgitation, 92% (54-99.2%) and 87% (62-97%) for thoracic aortic aneurysm and 39% (33.8-45%) and 94% (92-95%) for pericardial effusion. In this systematic review and meta-analysis, bedside-focused TTE has high specificity for type A and B dissection, a moderate to high sensitivity for type A but poor for type B, and unclear diagnostic accuracy for intramural haematoma and penetrating aortic ulcer.

Diagnostic accuracy of alternative biomarkers for acute aortic syndrome: a systematic review

BACKGROUND

D-dimer is the only biomarker currently recommended in guidelines for the diagnosis of acute aortic syndrome (AAS). We undertook a systematic review to determine whether any alternative biomarkers could be useful in AAS diagnosis.

METHODS

We searched electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2024. Diagnostic studies were eligible if they examined biomarkers other than D-dimer for diagnosing AAS compared with a reference standard test in people presenting to the ED with symptoms of AAS. Case-control studies were identified but excluded due to high risk of bias. Selection of studies, data extraction and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool were undertaken independently by at least two reviewers. We used narrative synthesis to summarise the findings.

RESULTS

We identified 2017 citations, included 13 cohort studies (n=76-999), and excluded 38 case-control studies. Methodological quality was variable, with most included studies having unclear or high risk of bias and applicability concerns in at least one item of the QUADAS-2 tool. Only two studies reported biomarkers with sensitivity and specificity comparable to D-dimer (ie, >90% and >50%, respectively). Wang et al reported 99.1% sensitivity and 84.9% specificity for soluble ST2; however, these findings conflicted with estimates of 58% sensitivity and 70.8% specificity reported in another study. Chun and Siu reported 95.6% sensitivity and 56.1% specificity for neutrophil count, but this has not been confirmed elsewhere.

CONCLUSION

There are many potential alternative biomarkers for AAS but few have been evaluated in more than one study, study designs are often weak and reported biomarker accuracy is modest or inconsistent between studies. Alternative biomarkers to D-dimer are not ready for routine clinical use.

PROSPERO REGISTRATION NUMBER

CRD42022252121.

Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis

STUDY OBJECTIVE

Acute aortic syndrome is a life-threatening emergency condition. Previous systematic reviews of D-dimer diagnostic accuracy for acute aortic syndrome have been contradictory and based on limited data, but recently published studies offer potential for a more definitive overview. We aimed to perform a systematic review and meta-analysis to determine the diagnostic accuracy of D-dimer for diagnosing acute aortic syndrome.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library from inception to February 2024. Additionally, the reference lists of included studies and other systematic reviews were thoroughly searched. All diagnostic cohort studies (prospective or retrospective) that assessed the use of D-dimer for diagnosing acute aortic syndrome compared with a reference standard test (eg, computed tomographic angiography (CTA), ECG-gated CTA, echocardiography, magnetic resonance angiography, operation, or autopsy) were included. Two independent reviewers completed study selection, data extractions and quality assessment using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Data were synthesized using a bivariate meta-analysis model.

RESULTS

Of 2017 potentially relevant citations, 25 cohort studies met the inclusion criteria, and 18 reporting the 500 ng/mL threshold were included in the primary meta-analysis. Risk of bias domains were mostly unclear due to limited study reporting. The summary sensitivity was 96.5% (95% credible interval [CrI] 94.8% to 98%) and summary specificity was 56.2% (95% CrI, 48.3% to 63.9%). Study specificity varied markedly from 33% to 86%, indicating substantial heterogeneity. Sensitivity analysis including the 7 studies reporting other thresholds showed summary sensitivity of 95.7% (95% CrI, 93.2% to 97.5%) and summary specificity of 57.5% (95% CrI, 50.1% to 64.6%).

CONCLUSION

D-dimer concentration has high sensitivity (96.5%) and moderate specificity (56.2%) for acute aortic syndrome, with some uncertainty around estimates due to risk of bias and heterogeneity. Previous meta-analysis reporting higher specificity may be explained by inclusion of case-control studies that may overestimate accuracy.

Diagnosis and management of acute aortic dissection in the emergency department

Acute aortic dissection is often misdiagnosed as a result of its atypical presentations. It affects 4000 patients a year in the UK of all ages, not just older patients, with increasing numbers of cases expected in the future because of the ageing population. Dissection of the aortic wall leads to sudden, severe pain, and commonly end-organ symptoms which must be recognised. Acute aortic dissection can be challenging to diagnose in the emergency department because of the multitude of possible presentations and the need for selective testing with Computed Tomography Angiography (CTA). Clinicians often miss acute aortic dissection because it is not considered in the differential diagnosis, and the challenge lies in identifying acute aortic dissection in a sea of complaints of chest, back and abdominal pain. There are several ways to improve diagnosis, including awareness campaigns, better education about patients in which to consider acute aortic dissection, and improved detection strategies including which patients should receive CTA. Clinical decision tools and biomarkers could help, but further research is required and is a research focus in emergency medicine. Once diagnosed, blood pressure control, analgesia and urgent surgery or transfer to enable this to occur with minimal delay is required.

How we manage a high D-dimer

D-dimer, a soluble fibrin degradation product that originates from plasmin-induced degradation of cross-linked fibrin, is an important biomarker of coagulation activation and secondary fibrinolysis that is routinely used to rule out venous thromboembolism (VTE), and to evaluate the risk of VTE recurrence, as well as the optimal duration of anticoagulant therapy. Besides VTE, D-dimer may be high due to physiologic conditions, including aging, pregnancy, and strenuous physical activity. In addition, several disorders have been associated with increased D-dimer levels, ranging from disseminated intravascular coagulation to infectious diseases and cancers. Thus, it is far from unusual for hematologists to have to deal with ambulatory individuals with increased D-dimer without signs or symptoms of thrombus formation. This narrative review is dedicated to the management of these cases by the hematologist.

Risk factors for one-year mortality following discharge in patients with acute aortic dissection: development and validation of a predictive model in a cross-sectional study

PURPOSE

This study was aimed to identify the risk factors that influence the mortality risk in patients with acute aortic dissection (AAD) within one year after discharge, and aimed to construct a predictive model for assessing mortality risk.

METHODS

The study involved 320 adult patients obtained from the Medical Information Mart for Intensive Care (MIMIC) database. Logistic regression analysis was conducted to identify potential risk factors associated with mortality in AAD patients within one year after discharge and to develop a predictive model. The performance of the predictive model was assessed using the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA). To further validate the findings, patient data from the First Affiliated Hospital of Guangxi Medical University (157 patients) were analyzed.

RESULTS

Univariate and multivariate logistic regression analyses revealed that gender, length of hospital stay, highest blood urea nitrogen (BUN_max), use of adrenaline, and use of amiodarone were significant risk factors for mortality within one year after discharge (p < 0.05). The constructed model exhibited a consistency index (C-index) and an area under the ROC curve of 0.738. The calibration curve and DCA demonstrated that these indicators had a good degree of agreement and utility. The external validation results of the model also indicated good predictability (AUC = 0.700, p < 0.05).

CONCLUSION

The personalized scoring prediction model constructed by gender, length of hospital stays, BUN_max levels, as well as the use of adrenaline and amiodarone, can effectively identify AAD patients with high mortality risk within one year after discharge.

Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome

BACKGROUND

The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. We describe characteristics of ED attendances with symptoms potentially associated with AAS, diagnostic performance of clinical decision tools (CDTs) and physicians and yield of CT aorta angiogram (CTA).

METHODS

This was a multicentre observational cohort study of adults attending 27 UK EDs between 26 September 2022 and 30 November 2022, with potential AAS symptoms: chest, back or abdominal pain, syncope or symptoms related to malperfusion. Patients were preferably identified prospectively, but retrospective recruitment was also permitted. Anonymised, routinely collected patient data including components of CDTs, was abstracted. Clinicians treating prospectively identified patients were asked to record their perceived likelihood of AAS, prior to any confirmatory testing. Reference standard was radiological or operative confirmation of AAS. 30-day electronic patient record follow-up evaluated whether a subsequent diagnosis of AAS had been made and mortality.

RESULTS

5548 patients presented, with a median age of 55 years (IQR 37-72; n=5539). 14 (0.3%; n=5353) had confirmed AAS. 10/1046 (1.0%) patients in whom the ED clinician thought AAS was possible had AAS. 5/147 (3.4%) patients in whom AAS was considered the most likely diagnosis had AAS. 2/3319 (0.06%) patients in whom AAS was considered not possible did have AAS. 540 (10%; n=5446) patients underwent CT, of which 407 were CTA (7%). 30-day follow-up did not reveal any missed AAS diagnoses. AUROC (area under the receiver operating characteristic) curve for ED clinician AAS likelihood rating was 0.958 (95% CI 0.933 to 0.983, n=4006) and for individual CDTs were: Aortic Dissection Detection Risk Score (ADD-RS) 0.674 (95% CI 0.508 to 0.839, n=4989), AORTAs 0.689 (95% CI 0.527 to 0.852, n=5132), Canadian 0.818 (95% CI 0.686 to 0.951, n=5180) and Sheffield 0.628 (95% CI 0.467 to 0.788, n=5092).

CONCLUSION

Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer.

TRIAL REGISTRATION NUMBER

NCT05582967; NCT05582967.

How artificial intelligence during the pandemic modified the role of a biomarker as d-dimer

Artificial intelligence (AI) was introduced in medicine to make some difficult decision-making regarding diagnostics and/or treatments easy. Its application derives from the improvement of information obtained with computer sciences and informatics, in particular with information derived by algorithms obtained with special informatics support as machine learning. The scenario of hospital changes induced by the COVID-19 pandemic makes easy the application of AI for some clinical updates. Being lung failure with pulmonary embolism is the most common cause of death for inpatients with COVID-19, some biomarkers such as the d-dimer are constantly used associated with other clinical features in order to improve medical assistance. For this reason, d-dimer during the pandemic changed its traditional use for predictive negative value in patients with suspected pulmonary embolism and took relevance for its values giving the chance to change the intensity of anticoagulation for several inpatients. In most cases, according to data reported from several cohorts, these changes improved the morbidity and mortality of a significant percentage of inpatients with COVID-19. The International medical prevention registry on venous thromboembolism and d-dimer and modified sepsis-induced coagulopathy scores were the most used scores derived from AI and dedicated to these clinical aspects in inpatients with COVID-19. Therefore, this review was dedicated to flexible changes that we can use after d-dimer values in different clinical scenarios that vary from disseminated intravascular coagulation to pulmonary embolism to COVID-19.

MiR-590-3p Promotes the Phenotypic Switching of Vascular Smooth Muscle Cells by Targeting Lysyl Oxidase

ABSTRACT

We investigated the clinical characteristics of patients with acute aortic dissection (AAD) and miR-590-3p levels in serum, tissue, and vascular smooth muscle cells. The effect of miR-590-3p on the vascular smooth muscle cell phenotype was assessed, and the regulation of lysyl oxidase by miR-5903p was determined. C57BL/6 mice were used to investigate the incidence of AAD and effects of miR-5903p on AAD. The miR-590-3p levels were measured in the aortae of mice, and hematoxylin and eosin staining and Masson staining were performed to identify the morphological features of the aorta. Comparative analysis revealed significant differences in clinical characteristics between patients with AAD and healthy control subjects, with most patients with AAD exhibiting concomitant hypertension and nearly 50% having atherosclerosis. Lysyl oxidase was a direct target of miR-590-3p. Lysyl oxidase overexpression inhibited switching of the vascular smooth muscle cell phenotype from contractile to synthetic, but miR-590-3p overexpression significantly reversed this change. In the mouse model, miR-590-3p upregulation increased the incidence of AAD to 93.3%, and its incidence decreased to 13.3% after miR-590-3p inhibition. Hematoxylin and eosin and Masson staining revealed that the miR-590-3p agomiR group had a greater loss of the contractile phenotype in the dissected aortic wall and an increased number of muscle fibers in the aortic wall, which contributed to thickening of the aortic wall and the formation of a false lumen in aortic dissection. miR-590-3p might be pivotal in the pathogenesis of AAD. Thus, targeting miR-590-3p or its downstream pathways could represent a therapeutic approach for AAD.

Acute and chronic venous occlusion

This review article provides an overview of acute and chronic venous occlusion, a condition that can cause significant morbidity and mortality if not diagnosed and treated promptly. The article begins with an introduction to the anatomy of the venous system, followed by a discussion of the causes and clinical features of venous occlusion. The diagnostic tools available for the assessment of venous occlusion, including imaging modalities such as ultrasound, CT, and MRI, are then discussed, along with their respective advantages and limitations. The article also covers the treatment options for acute and chronic venous occlusion, including anticoagulant therapy and endovascular interventions. This review aims to provide radiologists with an updated understanding of the pathophysiology, diagnosis, and management of acute and chronic venous occlusion.

[ROC curves: general characteristics and their usefulness in clinical practice]

The use of diagnostic tests to determine the presence or absence of a disease is essential in clinical practice. The results of a diagnostic test may correspond to numerical estimates that require quantitative reference parameters to be transferred to a dichotomous interpretation as normal or abnormal and thus implement actions for the care of a condition or disease. For example, in the diagnosis of anemia it is necessary to define a cut-off point for the hemoglobin variable and create two categories that distinguish the presence or absence of anemia. The method used for this process is the preparation of diagnostic performance curves, better known by their acronym in English as ROC (Receiver Operating Characteristic). The ROC curve is also useful as a prognostic marker, since it allows defining the cut-off point of a quantitative variable that is associated with greater mortality or risk of complications. They have been used in different prognostic markers in COVID-19, such as the neutrophil/lymphocyte ratio and D-dimer, in which cut-off points associated with mortality and/or risk of mechanical ventilation were identified. The ROC curve is used to evaluate the diagnostic performance of a test in isolation, but it can also be used to compare the performance of two or more diagnostic tests and define which one is more accurate. This article describes the basic concepts for the use and interpretation of the ROC curve, the interpretation of an area under the curve (AUC) and the comparison of two or more diagnostic tests.

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41-91% and 94-100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50-100% and 93-100%, respectively; for >45 mm ranges were 64-65% and 95-99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.

Cerebral Infarction as the Primary Presentation of Acute Aortic Dissection

Background

The aim of this study was to determine the clinical characteristics and outcome of patients with aortic dissection (AD) who present with an initial manifestation of cerebral infarction.

Methods

We retrospectively analyzed patients who were diagnosed with AD and admitted to the emergency department from May 1, 2017 to May 1, 2022. Data was collected for variables including age, sex, clinical manifestation, past medical history, and laboratory test results.

Results

Twenty-five patients (2.61%, 22 type A and 3 type B) showed cerebral infarction as the primary presentation for acute AD, while another 933 AD patients (471 type A and 462 type B) who presented with other symptoms served as the control group. Eighteen of the 25 patients (72%) were initially diagnosed with stroke, and the diagnosis of AD was missed. However, patients with a missed diagnosis of AD did not have significantly different mortality to those in whom AD was diagnosed (chi-square test, p > 0.9999). Patients with cerebral infarction as the first presentation had a higher incidence of type A AD than the control patients (p = 0.0002), while their mortality rate was also higher than the control group of AD patients (p < 0.0001). Furthermore, patients with cerebral infarction as the first presentation were more likely to have multiple organ dysfunction.

Conclusions

AD with an initial presentation of cerebral infarction is a rare condition with high mortality. However, the initial failure to diagnose AD does not further increase patient mortality.

D-dimer for assessment of treatment response, and survival to drug-eluting beads transarterial chemoembolization in hepatocellular carcinoma

BACKGROUND

D-dimer exhibits a certain prognostic value in hepatocellular carcinoma (HCC) patients who underwent hepatectomy and microwave ablation, while its value in estimating the clinical benefit of drug-eluting beads transarterial chemoembolization (DEB-TACE) remains unclear. Hence, this study aimed to investigate the correlation of D-dimer with tumor features, response and survival to DEB-TACE in HCC patients.

METHODS

Fifty-one HCC patients treated with DEB-TACE were recruited. Their serum samples at baseline and after DEB-TACE were collected and proposed for D-dimer detection by the immunoturbidimetry method.

RESULTS

Elevated D-dimer levels were related to a higher Child‒Pugh stage (P = 0.013), tumor nodule number (P = 0.031), largest tumor size (P = 0.004), and portal vein invasion (P = 0.050) in HCC patients. Then, patients were classified by the median value of D-dimer, and it was observed that patients with D-dimer >0.7 mg/L achieved a lower complete response rate (12.0% vs. 46.2%, P = 0.007) but a similar objective response rate (84.0% vs. 84.6%, P = 1.000) compared to those with D-dimer ≤0.7 mg/L. The Kaplan‒Meier curve showed that D-dimer >0.7 mg/L (vs. ≤0.7 mg/L) was related to shorter overall survival (OS) (P = 0.013). Further univariate Cox regression analyses showed that D-dimer >0.7 mg/L (vs. ≤0.7 mg/L) was related to unfavorable OS [hazard ratio (HR): 5.524, 95% confidence interval (CI): 1.209-25.229, P = 0.027], but it failed to independently estimate OS (HR: 10.303, 95%CI: 0.640-165.831, P = 0.100) in multivariate Cox regression analyses. Moreover, D-dimer was elevated during DEB-TACE therapy (P<0.001).

CONCLUSION

D-dimer may be helpful for monitoring prognosis to DEB-TACE therapy in HCC, while further large-scale-study validation is warranted.

Ischemia modified albumin can act as an independent predictor of inhospital mortality in patients with acute aortic dissection

Acute aortic dissection (AAD) is a serious disease characterized by high mortality. However, there are no accurate indicators to predict in-hospital mortality. The objective of this study was to identify the potential value of ischemia modified albumin (IMA) in prediction of in-hospital mortality of AAD patients. This was a single-center, prospective study involved 314 patients undergoing AAD, including 197 males and 117 females, aged 26-87 (57.14 ± 21.71) years old, 116 cases of TAAD and 198 cases of TBAD (37 cases of complicated, 114 cases of high risk, and 47 cases of uncomplicated), 228 cases were underwent surgery/intervention treatment (77 cases of TAAD,151 cases of TBAD) and 86 cases were underwent conservative therapy (39 cases of TAAD, 47 cases of TBAD). The basic data, on-admission IMA level, and the all-cause in-hospital mortality was recorded. IMA in the non-survivor group and TAAD group was found to be significantly higher than that in the survivor group and TBAD group (P < 0.001). Multivariate logistic regression analysis results revealed that age (OR = 1.923, 95%CI: 1.102-4.481, P = 0.020), conservative therapy (OR = 17.892, 95%CI: 7.641-24.748, P < 0.001), D-dimer level (OR = 3.517, 95%CI: 1.874-7.667, P = 0.011) and IMA level (OR = 5.406, 95%CI: 2.951-10.395, P = 0.004) served as independent risk factors for in-hospital mortality of TAAD patients. And D-dimer level (OR = 2.241, 95%CI: 1.475-5.663, P = 0.018), IMA level (OR = 3.115, 95%CI: 1.792-6.925, P = 0.009) also served as independent risk factors for in-hospital mortality of TBAD patients, whereas surgery (OR = 0.110, 95%CI: 0.075-0.269, P < 0.001) was the protective factor of in-hospital mortality of TAAD patients. After IMA prediction, the AUC, optimal cut-off value, sensitivity, and the specificity of in-hospital mortality of AAD patients were observed to be 0.801 (95%CI: 0.744-0.858), 86.55 U/mL, 79.1%, and 73.2%, respectively. In addition, it was found that AUC was 0.799 (95%CI: 0.719-0.880) in TAAD and 0.753 (95% CI: 0.641-0.866) in TBAD. Overall, it was concluded that on-admission IMA level acted as an independent prediction index for in-hospital mortality of AAD patients.

A sinister needle in an enormous haystack: A clinician survey regarding Acute Aortic Syndrome diagnostic practice in United Kingdom Emergency Departments

Acute Aortic Syndrome (AAS) is a life-threatening condition associated with high diagnostic uncertainty. This results in an unacceptable number of missed cases, which contributes to its high mortality. We designed and distributed a survey to Emergency Departments (EDs) across the United Kingdom to establish the standard practice for investigation and diagnosis of AAS across the UK. 56 EDs across the UK responded. The majority of these did not have a formal work-up pathway for AAS. The estimated CT scanning rates and missed cases of AAS were highly variable between departments. This suggests variation in practice and diagnostic uncertainty. Given its time sensitive nature, the need for a more standardised diagnostic pathway for AAS in EDs is evident. This may aid clinicians rule out AAS more safely and reduce the number of missed cases, which would in turn reduce the high morbidity and mortality associated with AAS.

Aortic dissection diagnosed with the aortic dissection detection risk score of 2 without D-dimer elevation

Acute aortic dissection can be fatal if overlooked, and the absence of D-dimer elevation can be used to exclude acute aortic dissection. However, we report a case of acute aortic dissection without D-dimer elevation. A man in his 70s presented to the emergency department with lumbar back pain. D-dimer was <1.0 µg/mL; however, acute aortic dissection was strongly suspected because of the sudden onset of lumbar back pain with a shifting location. Because of a difference in systolic blood pressure in both upper extremities, we performed a thorough examination using contrast-enhanced CT, leading to a diagnosis of acute aortic dissection. The patient was immediately referred to cardiovascular surgery and treated conservatively with antihypertensive management. The aortic dissection detection risk score (ADD-RS) classified the patient as high risk. This suggests the importance of using the D-dimer with the ADD-RS rather than solely relying on the D-dimer results to diagnose acute aortic dissection.

Extensive aortic dissection (Stanford Type A) presenting with confusion in a patient: a case report

Spontaneous extensive aortic dissection is rarely documented in the literature with a misdiagnosis rate of up to 38% in previous studies. Vital signs and clinical manifestations vary and depend on the extent of the dissection and location. We present a rare case of extensive Stanford Type A dissection in a 60-year-old female patient who presented with confusion. Type A aortic dissection is a surgical emergency that is important for clinicians to have a low threshold of suspicion of the life-threatening condition due to the diverse and potentially atypical clinical presentation of aortic dissection.

The diagnostic and prognostic value of D-dimer in different types of aortic dissection

Objective

To evaluate the serum D-dimer level and its diagnostic and prognostic predictive value in patients with different types of aortic dissection.

Methods

Eighty-four aortic dissection patients who were diagnosed clinically in our hospital from January 2017 to January 2021 were selected for the study. All patients were divided into Stanford type A (39 cases) and Stanford type B (45 cases) groups. The serum D-dimer level was detected at 1 h, 6 h, 12 h, 24 h, and 72 h after admission to the hospital, and its expression level with different types of aortic dissection was analyzed. The relationship between D-dimer and the prognosis of patients was also analyzed.

Results

The serum D-dimer levels of patients in group A were significantly higher than those in group B at 6 h, 12 h, 24 h, and 72 h after admission, and the differences were statistically significant. In group A, 16 patients died, and 23 patients survived, while in group B, 18 patients died, and 27 patients survived. The serum D-dimer level of the dead and surviving patients in group A was significantly higher than that of group B, and the serum D-dimer level of dead patients in groups A and B was significantly higher than that of surviving patients. For diagnostic value, the AUC was 0.89, sensitivity was 76.92%, specificity was 90.00% in group A, and the AUC was 0.82, sensitivity was 71.11%, and specificity was 85.00% in group B. For the prognostic predicted value, the AUC was 0.74 in group A, while the AUC was 0.69 in group B.

Conclusions

D-dimer has different serum levels in different types of aortic dissection patients, with higher levels in Stanford A. Serum D-dimer levels may be used as a better biomarker to diagnose the two types of aortic dissection and play an important role in patient prognostic prediction, especially Stanford type A.

Changes of Serum D-Dimer, NT-proBNP, and Troponin I Levels in Patients with Acute Aortic Dissection and the Clinical Significance

Objective

To investigate the changes in blood D-dimer (D-D), high-sensitivity troponin I (hs-cTnI), and N-terminal B-type brain natriuretic peptide (NT-proBNP) levels in patients with acute aortic dissection (AAD) and its clinical significance.

Methods

Forty patients with AAD diagnosed in our hospital from January 2018 to December 2019 were selected as the observation group, and 40 patients with chest pain and non-AAD treated in our hospital during the same period were included in the control group. The patients were subdivided into a death group and a survival group as per the prognosis. The clinical symptoms and signs of the two groups of patients upon admission were observed, and the levels of D-D, hs-cTnI, and NT-proBNP were determined. The differences in clinical data, plasma D-D, hs-cTnI, and NT-proBNP levels between the two groups of patients were analyzed.

Results

The clinical data and physical signs were homogeneous between the two groups (P > 0.05), while a significant elevation in the level of hs-cTnI in the control group was observed 24 h after admission (P < 0.05). The observation group showed significantly higher levels of D-D, NT-proBNP, and hs-cTnI than the control group (P < 0.05). The prevalence and surgical cure rate of Stanford A in the survival group were significantly lower in contrast with the death group, with an obvious higher intervention cure rate in the survival group. Higher D-dimer and NT-proBNP levels were identified at 24 h after admission versus upon admission, and the death group had a greater increase of D-dimer and NT-proBNP levels.

Conclusion

Clinical symptoms and signs are insufficient to constitute a diagnosis of AAD, whereas the elevated expression levels of D-D, hs-cTnI, and NT-proBNP demonstrated great potential for the diagnosis and prognosis of AAD.

A Retrospective Analysis of Serum D-Dimer Levels for the Exclusion of Acute Aortic Dissection

Purpose

Acute aortic dissection (AAD) is a highly fatal disorder if not promptly diagnosed. Some international studies have suggested that serum d-dimer levels may be used to exclude AAD, but data are limited. We sought to confirm that d-dimer levels are elevated in American patients with AAD. Additionally, we sought to estimate the test characteristics of the d-dimer for AAD.

Patients and Methods

We performed a retrospective analysis of patients in the Hospital Corporation of America database who arrived at the hospital between 2015 and 2019. We queried the database to find patients who had a diagnosis of AAD or (nonspecific) chest pain, and who also had a d-dimer performed within 24 hours of arrival at the hospital. The median d-dimer was compared in those diagnosed with AAD versus chest pain. We estimated the test characteristics of d-dimer for AAD at the standard cutoff value of 500 ng/mL.

Results

In total, 48,902 patients met the criteria for analysis, including 572 with AAD and 48,330 with chest pain. The median d-dimers were 2455 ng/mL and 385 ng/mL for the AAD and chest pain groups, respectively (p < 0.0001). Using a cutoff of 500 ng/mL, the sensitivity of the d-dimer was 91.1% and the specificity was 71.4%.

Conclusion

Serum d-dimer values are higher in patients with AAD than in those with nonspecific chest pain. At the standard cutoff of 500 ng/mL, the serum d-dimer has a high sensitivity for AAD, but not high enough that d-dimer levels alone can be used in isolation to exclude AAD.