D-dimer in aortic dissection

D-dimer in aortic dissection

The characteristic feature of D-dimer elevation in aortic dissection (AD) is that the levels are very high immediately after the dissection while in most other disorders associated with D-dimer elevation, the levels rise gradually. Hence the highest diagnostic yield of D-dimer estimation in suspected AD is in the first hour. It may be noted that D-dimer may be negative in intramural hematoma and penetrating atherosclerotic ulcer, two other important acute aortic syndromes [1].

Around one third of cases of aortic dissection may be missed on initial evaluation and hence D-dimer estimation may give a clue to the need for imaging studies. After evaluation 227 cases with suspected aortic dissection of which 87 were confirmed Suzuki T et al concluded that D-dimer may be useful in risk stratification if done within 24 hours of onset of symptoms [2]. 

A recent meta analysis showed that sensitivity and negative predictive value was high, though the specificity and positive predictive value were low [3]. They concluded that a D-dimer value below 500 ng/ml would identify subjects unlikely to benefit from aortic imaging.

ADvISED study was a prospective multi center study of acute aortic syndromes [4]. The value of D-dimer estimation along with aortic dissection detection risk score was evaluated. The study concluded that the combination of aortic dissection detection risk score and D-dimer estimation may be considered to standardize diagnostic rule out of acute aortic syndrome.

Elevated D-dimer levels at admission was found to be associated with 90 day post operative adverse events in patients with type A dissection undergoing arch replacement [5]. This was a retrospective analysis of 347 patients.

References

1. Sutherland A, Escano J, Coon TP. Ann Emerg Med 2008;52:339-343.
2. Suzuki T, Distante A, Zizza A, Trimarchi S, Villani M, Salerno Uriarte JA, De Luca Tupputi Schinosa L, Renzulli A, Sabino F, Nowak R, Birkhahn R, Hollander JE, Counselman F, Vijayendran R, Bossone E, Eagle K; IRAD-Bio Investigators. Circulation 2009;119:2702-2707.
3. Shimony A, Filion KB, Mottillo S, Dourian T, Eisenberg MJ. Am J Cardiol 2011;107:1227-1234.
4. Nazerian P, Mueller C, Soeiro AM, Leidel BA, Salvadeo SAT, Giachino F, Vanni S, Grimm K, Oliveira MT Jr, Pivetta E, Lupia E, Grifoni S, Morello F; ADvISED Investigators. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018 Jan 16;137(3):250-258.
5. Liu T, Zheng J, Zhang YC, Zhu K, Gao HQ, Zhang K, Jin XF, Xu SD. Association Between D-dimer and Early Adverse Events in Patients With Acute Type A Aortic Dissection Undergoing Arch Replacement and the Frozen Elephant Trunk Implantation: A Retrospective Cohort Study. Front Physiol. 2020 Jan 21;10:1627.