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Wren J, Goodacre S, Pandor A, Essat M, Clowes M, Cooper G, Hinchliffe R, Reed MJ, Thomas S, Wilson S. Diagnostic accuracy of alternative biomarkers for acute aortic syndrome: a systematic review. Emerg Med J 2024:emermed-2023-213772. [PMID: 39107052 DOI: 10.1136/emermed-2023-213772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 07/21/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND D-dimer is the only biomarker currently recommended in guidelines for the diagnosis of acute aortic syndrome (AAS). We undertook a systematic review to determine whether any alternative biomarkers could be useful in AAS diagnosis. METHODS We searched electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2024. Diagnostic studies were eligible if they examined biomarkers other than D-dimer for diagnosing AAS compared with a reference standard test in people presenting to the ED with symptoms of AAS. Case-control studies were identified but excluded due to high risk of bias. Selection of studies, data extraction and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool were undertaken independently by at least two reviewers. We used narrative synthesis to summarise the findings. RESULTS We identified 2017 citations, included 13 cohort studies (n=76-999), and excluded 38 case-control studies. Methodological quality was variable, with most included studies having unclear or high risk of bias and applicability concerns in at least one item of the QUADAS-2 tool. Only two studies reported biomarkers with sensitivity and specificity comparable to D-dimer (ie, >90% and >50%, respectively). Wang et al reported 99.1% sensitivity and 84.9% specificity for soluble ST2; however, these findings conflicted with estimates of 58% sensitivity and 70.8% specificity reported in another study. Chun and Siu reported 95.6% sensitivity and 56.1% specificity for neutrophil count, but this has not been confirmed elsewhere. CONCLUSION There are many potential alternative biomarkers for AAS but few have been evaluated in more than one study, study designs are often weak and reported biomarker accuracy is modest or inconsistent between studies. Alternative biomarkers to D-dimer are not ready for routine clinical use. PROSPERO REGISTRATION NUMBER CRD42022252121.
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Affiliation(s)
- Joshua Wren
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | | | | | - Graham Cooper
- Aortic Dissection Charitable Trust, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert Hinchliffe
- Department of Vascular Surgery, North Bristol NHS Trust, Westbury on Trym, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
- Acute Care Group, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Steven Thomas
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sarah Wilson
- Emergency Department, Wexham Park Hospital, Slough, UK
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Essat M, Goodacre S, Pandor A, Ren S, Ren S, Clowes M. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis. Ann Emerg Med 2024:S0196-0644(24)00260-9. [PMID: 38888529 DOI: 10.1016/j.annemergmed.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/28/2024] [Accepted: 05/01/2024] [Indexed: 06/20/2024]
Abstract
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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Affiliation(s)
- Munira Essat
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sa Ren
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Shijie Ren
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mark Clowes
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
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Jian M, Sun X, Li S, Wang H, Zhang H, Li X, He Y, Wang Z. Quantitative Detection of Multiple Cardiovascular Biomarkers by an Antibody Microarray-Based Metal-Enhanced Fluorescence Assay. Anal Chem 2024; 96:7353-7359. [PMID: 38690857 DOI: 10.1021/acs.analchem.4c00266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Accurate detection of multiple cardiovascular biomarkers is crucial for the timely screening of acute coronary syndrome (ACS) and differential diagnosis from acute aortic syndrome (AAS). Herein, an antibody microarray-based metal-enhanced fluorescence assay (AMMEFA) has been developed to quantitatively detect 7 cardiovascular biomarkers through the formation of a sandwich immunoassay on the poly(glycidyl methacrylate-co-2-hydroxyethyl methacrylate)-decorated GNR-modified slide (GNR@P(GMA-HEMA) slide). The AMMEFA exhibits high specificity and sensitivity, the linear ranges span 5 orders of magnitude, and the limits of detection (LODs) of cardiac troponin I (cTnI), heart-type fatty acid binding protein (H-FABP), C-reactive protein (CRP), copeptin, myoglobin, D-Dimer, and N-terminal pro-brain natriuretic peptide (NT-proBNP) reach 0.07, 0.2, 65.7, 0.6, 0.2, 8.3, and 0.3 pg mL-1, respectively. To demonstrate its practicability, the AMMEFA has been applied to quantitatively analyze 7 cardiovascular biomarkers in 140 clinical plasma samples. In addition, the expression levels of cardiovascular biomarkers were analyzed by the least absolute shrinkage and selector operator (LASSO) regression, and the area under receiver operator characteristic curves (AUCs) of healthy donors (HDs), ACS patients, and AAS patients are 0.99, 0.98, and 0.97, respectively.
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Affiliation(s)
- Minghong Jian
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Xudong Sun
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Shasha Li
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Haodong Wang
- Department of Cardiovascular, The China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Hua Zhang
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Xiaotong Li
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Yuquan He
- Department of Cardiovascular, The China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Zhenxin Wang
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
- National Analytical Research Center of Electrochemistry and Spectroscopy, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China
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Weir-McCall JR, Shambrook J. CT in Suspected Acute Aortic Syndrome: An Opportunity for Improving Cardiovascular Outcomes? Radiol Cardiothorac Imaging 2023; 5:e230129. [PMID: 37404784 PMCID: PMC10316295 DOI: 10.1148/ryct.230129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 07/06/2023]
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Waqanivavalagi SWFR, Bhat S, Schreve F, Milsom P, Bergin CJ, Jones PG. Trends in computed tomography aortography and acute aortic syndrome in an emergency department within Aotearoa New Zealand. Emerg Med Australas 2022; 34:769-778. [PMID: 35415971 PMCID: PMC9790442 DOI: 10.1111/1742-6723.13974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Acute aortic syndrome (AAS) comprises a triad of life-threatening aortic conditions that are difficult to diagnose because of their non-specific clinical presentations. Contrast-enhanced computed tomography aortography (CTA) has a high sensitivity and specificity for these conditions. However, under- and over-investigation of patients with suspected AAS using CTA carries significant risk. The aim of the present study was to evaluate the diagnostic imaging practices of CTA use for patients presenting to an ED with suspected AAS. METHODS All atraumatic thoracic CTAs performed on patients aged ≥15 years old with suspected AAS who presented to Auckland City Hospital between 2009 and 2019 were included. Outcomes of interest were the annual ED and population incidences of AAS, and the rate of CTAs performed. RESULTS A total of 1646 CTAs were included. There were 135 (8.2%) cases of at least one AAS diagnosis and 220 (13.4%) cases where an alternative diagnosis was made. The population-adjusted number of AAS diagnoses remained relatively stable over the study period, with a mean annual AAS incidence of 19.6 (95% confidence interval 9.9-33.7) per 100 000 patients, and 3.2 (95% confidence interval 1.6-5.4) per 100 000 population. The number of ED presentations increased during the study period, along with the population-adjusted rate of CTAs performed, from approximately 150 per 100 000 patients (2009) to 350 per 100 000 patients (2019). CONCLUSIONS Thoracic CTA use for investigating suspected AAS in our ED has recently increased. However, the annual incidence of AAS did not increase over the same period, but was higher than reported in overseas institutions.
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Affiliation(s)
- Steve WFR Waqanivavalagi
- Adult Emergency DepartmentAuckland City Hospital, Auckland District Health BoardAucklandNew Zealand,Department of MedicineThe University of AucklandAucklandNew Zealand,Green Lane Cardiothoracic Surgical UnitAuckland City Hospital, Auckland District Health BoardAucklandNew Zealand
| | - Sameer Bhat
- Department of SurgeryThe University of AucklandAucklandNew Zealand
| | - Franco Schreve
- Adult Emergency DepartmentAuckland City Hospital, Auckland District Health BoardAucklandNew Zealand
| | - Paget Milsom
- Green Lane Cardiothoracic Surgical UnitAuckland City Hospital, Auckland District Health BoardAucklandNew Zealand
| | - Colleen J Bergin
- Department of RadiologyAuckland City Hospital, Auckland District Health BoardAucklandNew Zealand
| | - Peter G Jones
- Adult Emergency DepartmentAuckland City Hospital, Auckland District Health BoardAucklandNew Zealand,Department of SurgeryThe University of AucklandAucklandNew Zealand
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Hamilton MCK, Harries I, Lopez-Bernal T, Karteszi H, Redfern E, Lyen S, Manghat NE. Electrocardiography-gated CT for acute aortic syndrome: quantifying the potential impact of subspecialty national recommendations on emergency general radiology reporting. Clin Radiol 2021; 77:e27-e32. [PMID: 34579863 DOI: 10.1016/j.crad.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/09/2021] [Indexed: 11/03/2022]
Abstract
AIM To evaluate the detection of acute aortic syndrome (AAS) and the prevalence of alternative diagnoses that may explain the presentation or require follow-up. MATERIALS AND METHODS This was a retrospective, blinded re-evaluation of consecutive electrocardiography (ECG)-gated computed tomography (CT) aortic studies by a cardiovascular radiologist performed between September 2019 and May 2020 in a tertiary-referral cardiothoracic centre. RESULTS There were 118 identified examinations, six examinations were excluded leaving 112 (mean age = 61 ± 17; 56% male). Three cases of AAS were present (prevalence 2.7%); only one was reported on initial review. There were no false-positive diagnoses of AAS. The heart was mentioned in 79 (70.5%) reports and 73 (65.2%) of reviews revealed a total of 114 new observations; 111 (97.4%) of these were cardiovascular with 44/112 (39.3%) patients potentially having a significant previously unsuspected cardiovascular diagnosis. CONCLUSION The implementation of national clinical guidance to increase testing and improve image quality led to a series of challenges. The real value of ECG-gated CT may lie in detecting other diseases that mimic AAS. With the additional workload, increased subspecialty expertise is required but there needs to be a willingness to learn with an adequate support infrastructure.
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Affiliation(s)
- M C K Hamilton
- Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK; Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - I Harries
- Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK; Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - T Lopez-Bernal
- Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - H Karteszi
- Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - E Redfern
- Department of Emergency Medicine, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - S Lyen
- Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK; Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - N E Manghat
- Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK; Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK.
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