European Heart Journal Advance Access originally published online on February 7, 2008
European Heart Journal 2008 29(6):829; doi:10.1093/eurheartj/ehn033
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D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study: reply
Department of Emergency Medicine
Vienna General Hospital, Medical School
Medical University Vienna
Waehringer Guertel 18–20
A-1090 Vienna
Austria
Department of Emergency Medicine
Vienna General Hospital, Medical School
Medical University Vienna
Waehringer Guertel 18–20
A-1090 Vienna
Austria
Tel: +43 1 40400 1964
Fax: +43 1 40400 1965
E-mail: hans.domanovits{at}meduniwien.ac.at
We congratulate Ohlmann et al.1 for their article covering the value of d-dimer in diagnosis and prognosis of acute aortic dissection (AAD). In contrast, we assessed the value of d-dimer testing for exclusion of AAD. A d-dimer <0.1 µg/mL will exclude AAD with 100% sensitivity.2 From a practical point view, our findings seem important for several reasons:
- According to the current guidelines, echocardiography, computed tomography, magnetic resonance imaging, and even angiography are recommended in any case of suspected aortic dissection. These diagnostic procedures are more or less invasive and expensive, with limited availability at different settings.3 We do agree that in patients, who present in critical care condition or with high pre-test probability for AAD, an aggressive approach is mandatory in rapid diagnosis of AAD. However, at least in patients with a low likelihood for AAD, applying d-dimer testing as a rapid point of care test will help to risk stratify patients at a very early time-point and to triage patients for more sophisticated diagnostic steps.
- As already known in the clinical setting of pulmonary embolism and deep venous thrombosis,4 d-dimer measurement is only unidirectional because of its lack of specificity; in suspected AAD, a negative result should be used in the diagnostic pathway to exclude disease. A positive result will be found in patients with AAD and other life-threatening or non-serious clinical conditions, demanding further investigations. This fact somewhat might limit the clinical utility of the d-dimer testing in AAD.
- We are aware that d-dimer assays with predefined cut-off levels will differ in sensitivity and negative predictive value in patients with suspected AAD. Therefore, as in pulmonary embolism, the capabilities and limitations of the particular d-dimer test applied have to be considered.4
References
- Ohlmann P, Faure A, Morel O, Petit H, Kabbaj H, Meyer N, Cheneau E, Jesel L, Epailly E, Desprez D, Grunebaum L, Schneider F, Roul G, Mazzucotteli JP, Eisenmann B, Bareiss P. Diagnostic and prognostic value of circulating D-dimers in patients with acute aortic dissection. Crit Care Med (2006) 5:1358–1364.
- Sodeck G, Domanovits H, Schillinger M, Ehrlich MP, Endler G, Herkner H, Laggner A. D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study. Eur Heart J (2007) 24:3067–3075.
- Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, Radegran K, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA. Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J (2001) 22:1642–1681.
[Free Full Text] - Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med (2004) 140:589–602.
[Abstract/Free Full Text]
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