Integrated Use of Conventional Chest Radiography Cannot Rule Out Acute Aortic Syndromes in Emergency Department Patients at Low Clinical Probability

Peiman Nazerian, Emanuele Pivetta, Simona Veglia, Edoardo Cavigli, Christian Mueller, Alexandre de Matos Soeiro, Bernd A Leidel, Enrico Lupia, Claudia Rutigliano, Desiree Wussler, Stefano Grifoni, Fulvio Morello, ADvISED Investigators, Peiman Nazerian, Emanuele Pivetta, Simona Veglia, Edoardo Cavigli, Christian Mueller, Alexandre de Matos Soeiro, Bernd A Leidel, Enrico Lupia, Claudia Rutigliano, Desiree Wussler, Stefano Grifoni, Fulvio Morello, ADvISED Investigators

Abstract

Objectives: Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AASs) if the pretest clinical probability is low. However, the diagnostic impact of CR integration for the rule-in and rule-out of AASs is unknown.

Methods: We performed a secondary analysis of the ADvISED multicenter study. Emergency department outpatients were eligible if an AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (ME) and other signs.

Results: In 2014 through 2016, a total of 1,129 patients were enrolled and 1,030 were analyzed, including 48 (4.7%) with AASs. ADD-RS/ME and ADD-RS/any CR sign (aCRs) integration were more accurate than ADD-RS alone (area under the curve = 0.8 and 0.78 vs. 0.66, p < 0.001). The sensitivity and specificity of the integrated strategies were 66.7% (95% confidence interval [CI] = 51.5% to 79.9%) and 82.5% (95% CI = 79.9% to 84.8%) for ADD-RS/ME and 68.8% (95% CI = 53.6% to 80.9%) and 76.5% (95% CI = 73.7% to 79.1%) for ADD-RS/aCRs, respectively. The sensitivity and specificity of CR per se were 54.2% (95% CI = 39.2% to 68.6%) and 92.4% (95% CI = 90.5% to 93.9%) for ME and 60.4% (95% CI = 45.3% to 74.2%) and 85.2% (95% CI = 82.9% to 87.4%) for aCRs. The agreement (κ) between attending physicians and radiologists for ME was 0.44 (95% CI = 0.35 to 0.54). ADD-RS/ME rule-in (ADD-RS ≤ 1 and ME-present, or ADD-RS > 1) applied to 204 versus 130 patients with ADD-RS > 1, including 14 with AAS and 60 false-positives (FP). ADD-RS/aCRs rule-in (ADD-RS ≤ 1 and aCRs-present, or ADD-RS > 1) applied to 264 patients, including 15 with AAS and 119 FP. ADD-RS/ME rule-out (ADD-RS ≤ 1 and ME-absent) applied to 826 (80.2%) patients, including 16 with AAS (33.3% of cases). ADD-RS/aCRs rule-out (ADD-RS ≤ 1 and aCRs-absent) applied to 766 patients (74.4%), including 15 with AAS (31.3% of cases).

Conclusions: CR integration with clinical probability assessment showed modest rule-in efficiency and insufficient sensitivity for conclusive rule-out.

Trial registration: ClinicalTrials.gov NCT02086136.

© 2019 by the Society for Academic Emergency Medicine.

References

    1. Baliga RR, Nienaber CA, Bossone E, et al. The role of imaging in aortic dissection and related syndromes. JACC Cardiovasc Imaging 2014;7:406-24.
    1. Kocher KE, Meurer WJ, Fazel R, Scott PA, Krumholz HM, Nallamothu BK. National trends in use of computed tomography in the emergency department. Ann Emerg Med 2011;58:452-62.e3.
    1. Zhan S, Hong S, Shan-Shan L, et al. Misdiagnosis of aortic dissection: experience of 361 patients. J Clin Hypertens (Greenwich) 2012;14:256-60.
    1. Ohle R, Anjum O, Bleeker H, Wells G, Perry JJ. Variation in emergency department use of computed tomography for investigation of acute aortic dissection. Emerg Radiol 2018;25:293-8.
    1. Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA 2002;287:2262-72.
    1. von Kodolitsch Y, Nienaber CA, Dieckmann C, et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med 2004;116:73-7.
    1. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266-369.
    1. Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011;58:2020-45.
    1. Erbel R, Aboyans V, Boileau C, et al. ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873-926.
    1. Nazerian P, Mueller C, Soeiro AM, 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;137:250-8.
    1. Rogers AM, Hermann LK, Booher 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;123:2213-8.
    1. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD) New Insights Into an Old Disease. JAMA 2000;283:897-903.
    1. Nazerian P, Morello F, Vanni S, et al. Combined use of aortic dissection detection risk score and D-dimer in the diagnostic workup of suspected acute aortic dissection. Int J Cardiol 2014;175:78-82.
    1. Hajian-Tilaki K. Sample size estimation in diagnostic test studies of biomedical informatics. J Biomed Inform 2014;48:193-204.
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-74.
    1. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988;44:837-45.
    1. Fagan TJ. Letter: nomogram for Bayes theorem. N Engl J Med 1975;293:257.
    1. Ohle R, Kareemi HK, Wells G, Perry JJ. Clinical examination for acute aortic dissection: a systematic review and meta-analysis. Acad Emerg Med 2018;25:397-412.
    1. Gleeson CE, Spedding RL, Harding LA, Caplan M. The mediastinum-is it wide? Emerg Med J 2001;18:183-5.
    1. Jagannath AS, Sos TA, Lockhart SH, Saddekni S, Sniderman KW. Aortic dissection: a statistical analysis of the usefulness of plain chest radiographic findings. AJR Am J Roentgenol 1986;147:1123-6.
    1. Luker GD, Glazer HS, Eagar G, Gutierrez FR, Sagel SS. Aortic dissection: effect of prospective chest radiographic diagnosis on delay to definitive diagnosis. Radiology 1994;193:813-9.
    1. Suzuki T, Eagle KA. Biomarker-assisted diagnosis of acute aortic dissection. Circulation 2018;137:270-2.

Source: PubMed

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