There are few diagnoses out there that most emergency physicians would say they have a “zero risk tolerance” for missing and thoracic aortic dissection (TAD) is undoubtedly one of them. If you have been practicing EM long enough, you will likely have cared for or heard about a “chest pain” patient who had a normal chest X-ray, no history of hypertension or other predisposing conditions whose dissection was missed. Two SNGH patients I recall included a CP Obs patient in his forties with no hx of HTN, a normal CxR and ECG who had a syncopal event while being wheeled to his stress-echo and died of a ruptured TAD. Another, was one of our ED nurses in his 40’s who had multiple negative work-ups for CP including CTA and stress studies only to return to the ED with recurrent CP and a massive dissection. He had a variant of Marfan’s despite his stature of 5’ 10”.  We will look at the utility of the D-dimer in the diagnoses of TAD as well as two decision rules. One is an attempt to validate an AHA decision rule derived by “experts” and the other by Nazerian and colleagues that combines d-dimer and the ADD-RS score which has been getting a lot of press. So, do we have sufficient evidence in support of the broad application of a new decision rule or is it just not ready for prime-time. Hope to see you there!  Charlie

Suzuki T et al,Diagnosis of acute aortic dissection by D-dimer: the International Registry of Acute Aortic Dissection Substudy on Biomarkers (IRAD-Bio) experience. Circulation. 2009 May 26;119(20):2702-7.  Appraisal

Rogers AM et al,Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation. 2011 May 24; 2213-8. Appraisal

Nazerian P et al, 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.  Appraisal