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Background: Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown. Methods: In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0–3) per current guidelines. DD was considered negative (DD−) if Results: A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6–98.6) and a specificity of 64% (95% CI, 61.6–66.4) for the diagnosis of AAS; 8 patients with AAS had DD−. In 294 patients with ADD-RS=0/DD−, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1.9) and an efficiency of 15.9% (95% CI, 14.3–17.6) for the ADD-RS=0/DD− strategy. In 924 patients with ADD-RS ≤1/DD−, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1) and an efficiency of 49.9% (95% CI, 47.7–52.2) for the ADD-RS ≤1/DD− strategy. Conclusions: Integration of ADD-RS (either ADD-RS=0 or ADD-RS ≤1) with DD may be considered to standardize diagnostic rule out of AAS. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02086136.

Pre-test probability assessment is key in the approach to suspected acute aortic syndromes (AASs). However, most patients with AAS-compatible symptoms are classified at low probability, warranting further evaluation for decision on aortic imaging. White blood cell count, platelet count and fibrinogen explore pathophysiological pathways mobilized in AASs and are routinely assayed in the workup of AASs. However, the diagnostic performance of these variables for AASs, alone and as a bundle, is unknown. We tested the hypothesis that white blood cell count, platelet count and/or fibrinogen at presentation may be applied as additional tools to standard clinical evaluation for pre-test risk assessment in patients at low probability of AAS.This was a retrospective observational study conducted on consecutive patients managed in our Emergency Department from 2009 to 2014 for suspected AAS. White blood cell count, platelet count and fibrinogen were assayed during evaluation in the Emergency Department. The final diagnosis was obtained by computed tomography angiography. The pre-test probability of AAS was defined according to guidelines. Of 1210 patients with suspected AAS, 1006 (83.1%) were classified at low probability, and 271 (22.4%) were diagnosed with AAS. Within patients at low probability, presence of at least one alteration among white blood cell count9*10In addition to standard clinical evaluation, white blood cell count and platelet count may be used in patients at low pre-test probability to fine-tune risk assessment of AAS.

The aortic dissection detection (ADD) risk score has been proposed by guidelines to standardise the approach to patients with suspected acute aortic dissection (AD). However, the ADD risk score has not been validated so far.Patients with suspected AD from two clinical centres were prospectively enrolled in a registry from 2008 to 2012. The ADD risk score was calculated retrospectively by review of medical charts, according to the number of risk categories where patients met criteria. Of 1328 patients, 291 (21.9%) were diagnosed with AD. The ADD risk score was=0 in 439 (33.1%) patients, =1 in 646 (48.6%) patients and1 in 243 (18.3%) patients. The incidence of AD was 5.9%, 27.3% and 39.1% respectively in patient groups identified by ADD risk score=0, =1 and1. ADD risk score0 had a sensitivity of 91.1% (95% confidence interval (CI) 87.2-94.1%) and a specificity of 39.8% (95% CI 36.8-42.9%) for the diagnosis of AD, while ADD risk score1 had a sensitivity of 32.7% (95% CI 27.3-38.4%) and a specificity of 85.7% (95% CI 83.5-87.8%). Among patients with ADD risk score=0, mediastinum widening on chest X-ray had a sensitivity of 16.7% (95% CI 3.6-41.4%) and a specificity of 86.3% (95% CI 81.9-90.0%).The ADD risk score stratifies patients for the risk of AD. ADD risk score0 is highly sensitive and poorly specific for the diagnosis in AD. The presence of ADD risk score=0 per se does not accurately exclude AD. In patients with ADD risk score=0, chest X-ray provides limited diagnostic information.

Purpose: The diagnosis of acute aortic dissection (AoD) constitutes a major challenge. To assist physicians, the American Heart Association (AHA) has proposed a detection risk score based on high-risk predisposing conditions, pain features and physical examination. Such score identifies patients at low, intermediate and high risk of AoD. In the low-risk group, absence of a widened mediastinum on chest X-ray has been suggested as a mean to safely rule out AoD without further aortic imaging. However, the AHA risk score and derived diagnostic algorithm is awaiting validation. The aim of our study was to evaluate the diagnostic performance of the AoD AHA risk score in the emergency department (ED). Methods: Consecutive adult patients suspected of AoD from 2 EDs were included in a prospective registry from January 2008 to December 2012. Patients were classified according to the AHA risk score and the prevalence of AoD was calculated in each risk group. Furthermore, we estimated the prevalence of AoD in low-risk patients with a not-widened mediastinum on chest X-ray (CXR). The final diagnosis of AoD was obtained with computed tomography, angiography, surgery or autopsy. Results: Among the 1279 patients (mean age 68 years) included in the study, 236 (18.4%) were diagnosed with AoD; 365 (28.5%) patients presented at least one predisposing high-risk condition, 358 (27.9%) a high-risk pain feature and 342 (26.7%) a high-risk physical examination finding. 461 (36%) patients were classified as low-risk, 595 (46.5%) as intermediate-risk and 223 (17.4%) as high-risk. The respective prevalence of AoD was 10.1%, 18.9% and 34% in the 3 groups. Among the 420 (91%) low-risk patients with available CXR, the mediastinum was not-widened in 28 (60%) of 47 patients with AoD. Hence, 6.6% of low-risk patients with a not-widened mediastinum on CXR had AoD. Conclusion: The AHA risk score correctly stratifies patients for AoD prevalence in the ED. However AoD can not safely be rule out in the low risk patients even if a not-widened mediastinum is detected at CXR.

Introduction Matrix metalloproteinases (MMPs) are involved in aortic pathophysiology. Preliminary studies have detected increased plasma levels of MMP8 and MMP9 in patients with acute aortic dissection (AAD). However, the performance of plasma MMP8 and MMP9 for the diagnosis of AAD in the emergency department is at present unknown. Methods The levels of MMP8 and MMP9 were measured by ELISA on plasma samples obtained from 126 consecutive patients evaluated in the emergency department for suspected AAD. All patients were subjected to urgent computed tomography (CT) scan for final diagnosis. Results In the study cohort (N = 126), AAD was diagnosed in 52 patients and ruled out in 74 patients. Median plasma MMP8 levels were 36.4 (interquartile range 24.8 to 69.3) ng/ml in patients with AAD and 13.2 (8.1 to 31.8) ng/ml in patients receiving an alternative final diagnosis (P