Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis - 18/06/24
, Abdullah Pandor, MSc, Sa Ren, MSc, PhD, Shijie Ren, MPhil, PhD, Mark Clowes, MScAbstract |
Study objective |
Acute aortic syndrome is a life-threatening emergency condition. Previous systematic reviews of D-dimer diagnostic accuracy for acute aortic syndrome have been contradictory and based on limited data, but recently published studies offer potential for a more definitive overview. We aimed to perform a systematic review and meta-analysis to determine the diagnostic accuracy of D-dimer for diagnosing acute aortic syndrome.
Methods |
We searched MEDLINE, EMBASE, and the Cochrane Library from inception to February 2024. Additionally, the reference lists of included studies and other systematic reviews were thoroughly searched. All diagnostic cohort studies (prospective or retrospective) that assessed the use of D-dimer for diagnosing acute aortic syndrome compared with a reference standard test (eg, computed tomographic angiography (CTA), ECG-gated CTA, echocardiography, magnetic resonance angiography, operation, or autopsy) were included. Two independent reviewers completed study selection, data extractions and quality assessment using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Data were synthesized using a bivariate meta-analysis model.
Results |
Of 2017 potentially relevant citations, 25 cohort studies met the inclusion criteria, and 18 reporting the 500 ng/mL threshold were included in the primary meta-analysis. Risk of bias domains were mostly unclear due to limited study reporting. The summary sensitivity was 96.5% (95% credible interval [CrI] 94.8% to 98%) and summary specificity was 56.2% (95% CrI, 48.3% to 63.9%). Study specificity varied markedly from 33% to 86%, indicating substantial heterogeneity. Sensitivity analysis including the 7 studies reporting other thresholds showed summary sensitivity of 95.7% (95% CrI, 93.2% to 97.5%) and summary specificity of 57.5% (95% CrI, 50.1% to 64.6%).
Conclusion |
D-dimer concentration has high sensitivity (96.5%) and moderate specificity (56.2%) for acute aortic syndrome, with some uncertainty around estimates due to risk of bias and heterogeneity. Previous meta-analysis reporting higher specificity may be explained by inclusion of case-control studies that may overestimate accuracy.
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| Prospero registration: Abdullah Pandor, Steve Goodacre, Munira Essat, Kate Ren, Mark Clowes, Sarah Ren. Diagnostic strategies for suspected acute aortic syndrome (AAS): Systematic review, meta-analysis, decision-analytic modeling, and value of information analysis. PROSPERO 2022 CRD42022252121. Available from: display_record.php?ID=CRD42022252121 |
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| Please see page XX for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Tyler W. Barrett, MD, MSCI. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: SG and AP coordinated the study. SG, AP, ShR, ME, and MC were responsible for conception, design, and obtaining funding for the study. MC developed the search strategy, undertook searches, and organized retrieval of papers. AP, ME, SG, SaR, and ShR were responsible for the acquisition, analysis, and interpretation of data. ME, AP, and SG were responsible for the drafting of this paper. All authors provided comments on the drafts and read and approved the final version. SG is the guarantor for the paper. |
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| Data sharing statement: All data relevant to the study are included in the article or uploaded as supplementary information. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). This study was funded by the United Kingdom National Institute for Health and Care Research Health Technology Assessment Programme (project number 151853). The views expressed in this paper are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Any errors are the responsibility of the authors. The funders had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. AP, SG, ME, MC, and ShR all declare grant funding for research to the University of Sheffield, UK from the National Institute for Health and Care Research Health Technology Assessment Programme, UK (project number 151853). There are no other competing interests. |
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| Disclosures: The project was funded by the United Kingdom National Institute for Health and Care Research Health Technology Assessment Programme and as such is covered by Crown copyright. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Author Accepted Manuscript version arising from this submission. |
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