The ADD-RS rules out aortic dissection
The Aortic Dissection Detection Risk Score (ADD-RS) should be used for low- to moderate-risk patients for whom acute aortic syndromes (AAS) are in the differential diagnosis. This tool, used in combination with a D-dimer test, has been proposed and internally validated as a diagnostic algorithm. There are significant caveats to the tool, including the following:
The ADD-RS may reduce misdiagnosis and overtesting for AAS, thereby avoiding unnecessary radiation exposure and the cost associated with definitive imaging. Consider using this risk stratification algorithm in patients who are at low risk for aortic dissection but for whom the diagnosis cannot be ruled out. The ADD-RS has a scoring range of 0 to 3; patients can be given just 1 point for each category (predisposing conditions, pain features, and exam findings). Thus, the score does not account for a patient who meets multiple criteria within a category. Patients meeting multiple criteria in a given category may not be appropriate candidates for the algorithm.
In 2010, the American Heart Association and the American College of Cardiology released guidelines for the diagnosis and management of AAS, including a set of 12 clinical markers of the disease. Rogers et al (2011) used retrospective data from the International Registry of Acute Aortic Dissection to validate the sensitivity of these markers. Among 2538 patients with acute aortic dissection, 2430 patients (95.7%) were identified by 1 or more of the 12 proposed clinical risk markers.
The International Registry of Acute Aortic Dissection investigators (Suzuki 2009) also performed a prospective multicenter study of 220 patients with initial suspicion for acute aortic dissection. Eighty-seven of those patients were ultimately diagnosed with acute aortic dissection. The widely used D-dimer cutoff of <500 ng/mL showed promise for ruling out AAS, with a negative likelihood ratio of 0.07 through the first 24 hours and a sensitivity of 96.6%.
The authors of the ADvISED trial (Nazerian 2018) designed and tested the ADD-RS/D-dimer novel clinical pathway for ruling out acute aortic dissection, combining clinical risk stratification with D-dimer as a serum biomarker. This multicenter prospective observational trial enrolled 1850 consecutive chest pain patients, 241 (13%) of whom were diagnosed with AAS. An ADD-RS score of ≤1 and a negative D-dimer result demonstrated a sensitivity of 98.8%, a negative predictive value of 99.7%, and a negative likelihood ratio of 0.02. The shortcomings of this study included the following:
Peiman Nazerian, MD
Anthony Hackett, DO, FACEP, FAAEM, FRSM; Jonathan Stuart, DO, MS; Douglas L. Robinson, DO, MS
Daniel Eraso, MD; Trevor Pour, MD
December 1, 2021
December 1, 2024
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.