D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction

Daiki Kaito; Ryo Yamamoto; Rakuhei Nakama; Kenichi Hashizume; Koji Ueno; Junichi Sasaki

doi:10.1016/j.ajem.2022.07.024

D-dimer for screening of aortic dissection in patients with ST-elevation myocardial infarction

Am J Emerg Med. 2022 Sep:59:146-151. doi: 10.1016/j.ajem.2022.07.024. Epub 2022 Jul 16.

Authors

Daiki Kaito¹, Ryo Yamamoto², Rakuhei Nakama³, Kenichi Hashizume⁴, Koji Ueno⁵, Junichi Sasaki¹

Affiliations

¹ Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
² Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan. Electronic address: ryo.yamamoto@gmail.com.
³ Department of Diagnostic Radiology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan.
⁴ Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi 321-0974, Japan.
⁵ Department of Cardiology, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi 321-0974, Japan.

PMID: 35868207
DOI: 10.1016/j.ajem.2022.07.024

Abstract

Background: Acute aortic dissection (AAD) with concurrent ST-segment elevation myocardial infarction (STEMI) is relatively rare and sometimes overlooked. As D-dimer testing has been reported to have high sensitivity to diagnose AAD in a clinical scale, Aortic Dissection Detection Risk Score (ADD-RS), a point-of-care D-dimer analyzer capable of measuring in 10 min would be useful to deny AAD with concurrent STEMI. However, an optimal cut-off value of D-dimer in such population remains unclear. Therefore, the aim of this study was to elucidate the optimal D-dimer threshold in patients clinically diagnosed with STEMI.

Methods: This retrospective cohort study was conducted at two tertiary care centers between 2014 and 2019. Patients clinically diagnosed with STEMI who underwent serum D-dimer measurement on hospital arrival were included. The primary outcome was the diagnosis of AAD. The area under the receiver operating characteristic curve (AUROC) for D-dimer values to diagnose AAD was evaluated, particularly in patients with low to moderate risks of AAD (1 of ADD-RS). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with several cut-off values.

Results: A total of 322 patients were included, and 28 were diagnosed with AAD. The AUROC for D-dimer to diagnose AAD was 0.970 (95% confidence interval: 0.948-0.993) in 262 patients with 1 of ADD-RS. If D-dimer ≥750 ng/mL was used as a cut-off value, sensitivity, specificity, PPV and NPV were 100%, 86.4%, 37.7%, and 100%, respectively. AAD could be denied in 209 (79.8%) patients using the cut-off value (D-dimer <750 ng/mL).

Conclusions: Serum D-dimer ≥750 ng/mL exhibited high sensitivity and NPV to diagnose AAD with concurrent STEMI, while the ADD-RS originally utilized ≥500 ng/mL as a cut-off for any suspected AAD. A point-of-care D-dimer measurement with the new cut-off would be useful to rule-out AAD among patients with STEMI.

Keywords: Aortic dissection; D-dimer; Diagnosis; Emergency department; STEMI.

MeSH terms

Aortic Aneurysm* / diagnosis
Aortic Dissection* / complications
Aortic Dissection* / diagnosis
Biomarkers
Fibrin Fibrinogen Degradation Products
Humans
Retrospective Studies
ST Elevation Myocardial Infarction* / diagnosis

Substances

Biomarkers
Fibrin Fibrinogen Degradation Products
fibrin fragment D