Admission Values of D-dimer and C-reactive Protein (CRP) Predict the Long-term Outcomes in Acute Aortic Dissection

A comprehensive exploration of novel biomarkers for the early diagnosis of aortic dissection

Aortic dissection (AD) is a catastrophic life-threatening cardiovascular emergency with a 1-2% per hour mortality rate post-diagnosis, characterized physiologically by the separation of aortic wall layers. AD initially presents as intense pain that can then radiate to the back, arms, neck, or jaw along with neurological deficits like difficulty in speaking, and unilateral weakness in some patients. This spectrum of clinical features associated with AD is often confused with acute myocardial infarction, hence leading to a delay in AD diagnosis. Cardiac and vascular biomarkers are structural proteins and microRNAs circulating in the bloodstream that correlate to tissue damage and their levels become detectable even before symptom onset. Timely diagnosis of AD using biomarkers, in combination with advanced imaging diagnostics, will significantly improve prognosis by allowing earlier vascular interventions. This comprehensive review aims to investigate emerging biomarkers in the diagnosis of AD, as well as provide future directives for creating advanced diagnostic tools and imaging techniques.

Eosinophil Recovery Time Is Associated with Clinical Outcomes in Patients with Type A Acute Aortic Dissection: a Retrospective Cohort Study

Type A acute aortic dissection (TA-AAD) patients are prone to life-threatening complications and death. This study aimed to analyze the association between eosinophil (EOS) recovery and clinical outcomes in TA-AAD. A total of 274 patients with TA-AAD were eligible for inclusion, and 54 patients died within 1 month. The patients with poor clinical outcomes showed significantly lower EOS count within 8 days after surgery. The time-dependent ROC analysis showed that EOS recovery days predicted 1-month death with an AUC of 0.886 and a cutoff of 6 days. EOS recovery within 6 days was associated with a lower incidence of postoperative infection, a poorer prognosis, and a lower risk of 1-month and 6-month mortality than those requiring more recovery days. Collectively, postoperative early recovery of EOS predicted lower mortality and better prognosis and may be applied as an effective, rapid, and simple tool for the risk stratification and prognostic prediction of patients with TA-AAD.Clinical trial registration number: NCT05409677.

Quantitative Detection of Multiple Cardiovascular Biomarkers by an Antibody Microarray-Based Metal-Enhanced Fluorescence Assay

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.

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

High Serum VE-Cadherin and Vinculin Concentrations Are Markers of the Disruption of Vascular Integrity during Type B Acute Aortic Dissection

BACKGROUND

In the present study, we measured the serum vascular endothelial cadherin (VEC) and vinculin (Vcn) concentrations in patients with type B acute aortic dissection (TBAD) to evaluate their diagnostic value for this condition.

METHODS

A total of 100 patients with TBAD and 90 matched controls were included in the study. The serum concentrations of VEC and Vcn were measured using enzyme-linked immunosorbent assays.

RESULTS

The serum VEC and Vcn concentrations were significantly higher in participants with TBAD than in healthy controls. Compared with patients with acute myocardial infarction (AMI), the serum concentrations of VEC and Vcn in patients with TBAD were higher, and the Vcn showed significant difference, with statistical significance. Receiver operating characteristic analysis generated areas under the curves for VEC and Vcn that were diagnostic for TBAD (0.599 and 0.655, respectively). The optimal cut-off values were 3.975 ng/μL and 128.1 pg/mL, the sensitivities were 43.0% and 35.0%, and the specificities were 73.3% and 90.0%, respectively. In addition, the use of a combination of serum VEC and Vcn increased the AUC to 0.661, with a sensitivity of 33.0% and a specificity of 93.33%. A high serum Vcn concentration was associated with a higher risk of visceral malperfusion in participants with TBAD (odds ratio (OR) = 1.007, 95% confidence interval [CI]: 1.001-1.013, p = 0.014). In participants with refractory pain, the adjusted OR for the serum VEC concentration increased to 1.172 (95% CI: 1.010-1.361; p = 0.036), compared with participants without refractory pain.

CONCLUSION

This study is the first to show the diagnostic value of serum VEC and Vcn for AAD and their relationships with the clinical characteristics of patients with TBAD. Thus, VEC and Vcn are potential serum markers of TBAD.

Evaluation of descriptive performances of platelet indices, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio in aortic dissections

OBJECTIVE

Mechanical damage resulting from aortic dissection creates a thrombus in the false lumen, in which platelets are involved. Platelet index is useful for the function and activation of platelets. The aim of this study was to show the clinical relevance of the platelet index of aortic dissection.

METHODS

A total of 88 patients diagnosed with aortic dissection were included in this retrospective study. Demographic data and hemogram and biochemistry results of the patients were determined. Patients were divided into two groups: deceased and surviving patients. The data obtained were compared with 30-day mortality. The primary outcome was the relationship of platelet index with mortality.

RESULTS

A total of 88 patients, 22 of whom were female (25.0%), diagnosed with aortic dissection, were included in the study. It was determined that 27 (30.7%) of the patients were mortal. The mean age of the entire patient group was 58±13 years. According to the DeBakey classification of aortic dissection of the patients, the percentages of the 1-2-3 type were determined as 61.4, 8.0, and 30.7%, respectively. Platelet index was not found to be directly related to mortality. Increase in age, decrease in bicarbonate value, and presence of diabetes mellitus were associated with mortality.

CONCLUSION

Although there were no significant changes in platelet index in aortic dissection, neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were found to be high in line with the literature. In particular, the presence of advanced age diabetes mellitus and decrease in bicarbonate are associated with mortality.

Current Understanding of Aortic Dissection

The aorta is the largest artery in the body, delivering oxygenated blood from the left ventricle to all organs. Dissection of the aorta is a lethal condition caused by a tear in the intimal layer of the aorta, followed by blood loss within the aortic wall and separation of the layers to full dissection. The aorta can be affected by a wide range of causes including acute conditions such as trauma and mechanical damage; and genetic conditions such as arterial hypertension, dyslipidaemia, and connective tissue disorders; all increasing the risk of dissection. Both rapid diagnostic recognition and advanced multidisciplinary treatment are critical in managing aortic dissection patients. The treatment depends on the severity and location of the dissection. Open surgical repair is the gold standard of treatment for dissections located to the proximal part of the aorta and the arch, while endovascular interventions are recommended for most distal or type B aortic dissections. In this review article, we examine the epidemiology, pathophysiology, contemporary diagnoses, and management of aortic dissection.

Short- and Mid-Term Survival Prediction in Patients with Acute Type A Aortic Dissection Undergoing Surgical Repair: Based on the Systemic Immune-Inflammation Index

Purpose

The postoperative survival of patients with acute type A aortic dissection (aTAAD) remains unsatisfactory. The current study developed an easy-to-use survival prediction model and calculator.

Methods

A total of 496 patients with aTAAD undergoing surgical repair were included in this study. The systemic immune-inflammation index (SII) and other clinical features were collected and subjected to logistic and Cox regression analyses. The survival prediction model was based on Cox regression analyses and exhibited as a nomogram. For convenience of use, the nomogram was further developed into calculator software.

Results

We demonstrated that a higher preoperative SII was associated with in-hospital death (OR: 4.116, p < 0.001) and a higher postoperative overall survival rate (HR: 2.467, p < 0.001) in aTAAD patients undergoing surgical repair. A survival prediction model and calculator based on SII and four other clinical features were developed. The overall C-index of the model was 0.743. The areas under the curves (AUCs) of the 1- and 3-month and 1- and 3-year survival probabilities were 0.73, 0.71, 0.71 and 0.72, respectively. The model also showed good calibration and clinical utility.

Conclusion

Preoperative SII is significantly associated with postoperative survival. Based on SII and other clinical features, we created the first easy-to-use prediction model and calculator for predicting the postoperative survival rate in aTAAD patients, which showed good prediction performance.

Serum Oxylipin Profiles Identify Potential Biomarkers in Patients with Acute Aortic Dissection

Aortic dissection (AD) is a life-threatening cardiovascular disease with a dismal prognosis. Inflammation plays an important role in AD. Oxylipins are bioactive lipids involved in the modulation of inflammation and may be involved in the pathogenesis and progression of AD. This study aims to identify possible metabolites related to AD. A total of 10 type A Aortic dissection (TAAD) patients, 10 type B Aortic dissection (TBAD) patients and 10 healthy controls were included in this study. Over 100 oxylipin species were identified and quantified by liquid chromatography with tandem mass spectrometry (LC-MS/MS) analysis. Our investigation demonstrated substantial alterations in 91 oxylipins between AD and healthy individuals. Patients with TAAD had 89 entries accessible compared to healthy controls. According to orthogonal partial least squares discriminant analysis (OPLS-DA), fitness (R²X = 0.362 and R²Y = 0.807, p = 0.03) and predictability (Q² = 0.517, p = 0.005) are the validation parameters between the two groups. Using multivariate logistic regression, 13-HOTrE and 16(17)-EpDPE were the risk factors in the aortic patients group compared to healthy people (OR = 2.467, 95%CI:1.256–7.245, p = 0.035; OR = 0.015, 95%CI:0.0002–0.3240, p = 0.016, respectively). In KEGG enrichment of differential metabolites, the arachidonic acid metabolism pathway has the most metabolites involved. We established a diagnostic model in distinguishing between AD and healthy people. The AUC was 0.905. Oxylipins were significantly altered in AD patients, suggesting oxylipin profile is expected to exploit a novel, non-invasive, objective diagnosis for AD.

High Neutrophil-to-Platelet Ratio Is Associated with Poor Survival in Patients with Acute Aortic Dissection

BACKGROUND

Acute aortic dissection (AAD), a serious and fatal cardiovascular disease, is characterized by inflammation that may further aggravate the condition. We evaluated the value of the neutrophil-to-platelet ratio (NPR) in the prognosis of AAD.

METHODS

We collected records of patients with AAD and clinical data from 2010 to 2020 and followed up on the relevant information for 136 months. The Kaplan-Meier (K-M) survival along with the univariate and multivariate Cox analyses was used to examine the prognostic value of NPR in AAD. In addition, nomograms were constructed by combining NPR, age, Stanford typing, and treatment methods. The accuracy of nomograms was evaluated using calibration plots, and the prediction efficiency of nomograms was evaluated by receiver operating characteristic curve analysis and decision curve analysis (DCA).

RESULTS

The K-M analysis showed that AAD patients with higher NPR exhibited worse prognosis. In addition, different Stanford typing and treatment methods produced varied prognosis results. Univariate and multivariate Cox analyses showed that NPR value, age, classification, and treatment were independent prognostic factors for the overall survival time of patients with AAD. Nomograms constructed by combining NPR, age, Stanford typing, and treatment methods showed good predictive efficacy, and the AUC values for 1-, 3-, and 5-year predicting were 0.82, 0.79, and 0.74, respectively.

CONCLUSIONS

Our results suggest that pretreatment NPR can be used as a potential prognostic marker of overall survival time in patients with AAD.

The diagnostic value of D-dimer in acute aortic dissection: a meta-analysis

Objective

This study aims to evaluate the diagnostic value of D-dimer for acute aortic dissection (AAD) by the method of meta-analysis.

Methods

PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang databases from the establishment of the databases to December 2020 were systematically searched, and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) system was used to evaluate the quality of the literature. STATA 15.0 software was applied to calculate the pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (+LR), negative likelihood ratio (−LR) to draw summary receiver operating characteristics (SROC) curve and calculate the area under the curve (AUC). Meta-regression and subgroup analyses were used to explore the source of heterogeneity.

Results

A total of 16 clinical studies were enrolled in this study, including 1135 patients. The results of the meta-analysis showed that the pooled sensitivity was 0.96 (95% CI 0.91–0.98), the pooled specificity was 0.70 (95% CI 0.57–0.81), and the pooled DOR was 56.57 (95% CI 25.11–127.44), the pooled +LR was 3.25 (95% CI 2.18–4.85), the pooled −LR was 0.06 (95% CI 0.03–0.12), and the AUC was 0.94 (95% CI 0.91–0.95). Meta-regression and subgroup analysis results showed that publication year, sample size and cutoff value might be sources of heterogeneity. When the concentration of D-dimer was less than or equal to 500 ng/ml, the sensitivity significantly increased.

Conclusion

D-dimer has an excellent diagnostic value for AAD. It is a useful tool for detecting suspected AAD because of the excellent pooled sensitivity. D-dimer ≤ 500 ng/ml increases the potential to identify the suspected patients with AAD.

Admission white blood cell count predicts post-discharge mortality in patients with acute aortic dissection: data from the MIMIC-III database

BACKGROUND

Inflammation underlies both the pathogenesis and prognosis in patients with acute aortic dissection (AAD). This study aimed to assess the association of ICU admission of white blood cell count (WBCc) with post-discharge mortality in these patients.

METHODS

Clinical data were extracted from the MIMIC-III V1.4 database. After adjusted to covariables, Cox regression analysis and Kaplan-Meier survival curve were performed to determine the relationship between WBCc on admission and post-discharge mortality (30-day, 90-day, 1-year and 5-year) in AAD patients. Subgroup analysis and receiver operating characteristic (ROC) curve analysis were used to test the performance of WBCc in predicting mortality in AAD patients.

RESULTS

A total of 325 eligible patients were divided into 2 groups: normal-WBCc group (≤ 11 k/uL) and high-WBCc group (> 11 K/uL). In univariate Cox regression analysis, high WBCc was significant risk predictor of 30-day, 90-day, 1-year and 5-year mortality [hazard ratio (HR), 95% CI, P 2.58 1.36-4.91 0.004; 3.16 1.76-5.70 0.000; 2.74 1.57-4.79 0.000; 2.10 1.23-3.54 0.006]. After adjusting for age and other risks, high WBCc remained a significant predictor of 30-day, 90-day and 1-year mortality in AAD patients (HR, 95% CI, P 1.994 1.058-3.76 0.033; 2.118 1.175-3.819 0.013; 2.37 1.343-4.181 0.003). The area under ROC curve of WBCc for predicting 30-day, 90-day, 1-year and 5-year mortality were 0.69, 0.70, 0.66 and 0.61, respectively. The results from subgroups analysis showed that there was no interaction in most strata and patients who were younger than 69 years of age or had history of respiratory disease with an elevated WBCc had an excess risk of 30-day mortality (HR, 95% CI, P 3.18 1.41-7.14 0.005; 3.84 1.05-14.13 0.043).

CONCLUSIONS

Higher than normal WBCc on admission may predict post-discharge mortality in patients with AAD.

Prognostic nutritional index predicts in-hospital mortality in patients with acute Stanford type A aortic dissection

BACKGROUND

Acute Stanford type A aortic dissection (ATAAD) is a life-threatening medical emergency. The aim of this study was to investigate the clinical significance of the prognostic nutritional index (PNI) as a novel inflammatory marker for ATAAD patients undergoing surgical repair.

METHODS

We retrospectively examined the medical records of 151 ATAAD patients who treated surgically. Patients were divided into two groups (survival and death) and these groups were compared with respect to clinical and laboratory parameters. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm³). Logistic regression analyses were performed to identify the risk factors of in-hospital mortality.

RESULTS

The mean age of the study cohort was 61 ± 12 years, 99 (65.6%) were males, and 35 (23.2%) patients died during the hospital stay. The PNI levels were significantly lower in death group compared with survival group (32.80 ± 4.90 vs. 37.94 ± 5.42, p < 0.001). Multivariate analysis showed that the PNI (OR: 0.795, p = 0.005), age (odds ratio [OR]: 1.085, p = 0.034), operating time (OR: 1.660, p = 0.042), and D-dimer (OR: 1.002, p = 0.001) independently predicted in-hospital mortality. The calculated cutoff value of the PNI was 33.01.

CONCLUSION

Lower PNI values are independently associated with in-hospital mortality in ATAAD. The PNI may be a useful tool for predicting the early mortality of ATAAD patients after surgical repair.

Patients with markedly elevated D-dimer who do not have pulmonary embolism

OBJECTIVE

To determine the cause of a markedly raised D-dimer among patients in whom a diagnosis of pulmonary embolism (PE) has been excluded by CT pulmonary angiogram (CTPA) with particular reference to new cases of cancer and aortic dissection.

METHODS

One thousand consecutive patients, suspected of PE, who had undergone CTPA and for whom a D-dimer had been requested, were seen between 2012 and 2016. Retrospectively we examined the case records of all those in the top quintile of the D-dimer distribution whose CTPA was negative for PE. D-dimer in the top quintile ranged from 7.5 to 260 times upper limit normal.

RESULTS

Eighty-five patients fulfilled our inclusion criteria. The likely causes of their very high D-dimer were infection (n=35, 41.2%), cardiovascular disease (n=12, 14.1% including two patients with previously undiagnosed aortic dissection), surgery or trauma (n=12, 14.1%), new or active cancer (n=9, 10.6% comprising six new cancers and three patients with cancers diagnosed previously that were considered to be active) and miscellaneous causes (n=17, 20.0%). Thirty-five patients (43.5%) died over a 2-year follow-up. Kaplan-Meier survival analysis showed poorer outcomes for patients with new or active cancer, when compared with those with no known cancer (p<0.001).

CONCLUSIONS

We have shown that a small proportion of patients suspected of PE whose D-dimers are markedly elevated have diagnoses we would not want to miss including previously unsuspected cancer and aortic dissection. Further studies will be required to define the optimal workup of patients with extremely high D-dimer who do not have venous thromboembolism.

Association of Lactate Dehydrogenase with In-Hospital Mortality in Patients with Acute Aortic Dissection: A Retrospective Observational Study

Background

Evidence regarding the relationship between serum lactate dehydrogenase (LDH) levels and in-hospital mortality in acute aortic dissection (AAD) patients is extremely limited. We aimed to investigate the relationship between LDH and in-hospital mortality in AAD patients.

Methods

The present study was a retrospective observational study. A total of 1526 participants with acute aortic dissection were involved in a hospital in China from January 2014 to December 2018. The target-independent variable was LDH measured at baseline, and the dependent was all-cause mortality during hospitalization. Covariates involved in this study included age, gender, body mass index (BMI), hypertension, diabetes, smoking, stroke, atherosclerosis, systolic blood pressure (SBP), diastolic blood pressure (DBP), white blood cell (WBC), hemoglobin (Hb), alanine transaminase (ALT), aspartate aminotransferase (AST), albumin (ALB), creatinine (Cr), symptom, type of AAD (Stanford), and management.

Results

The average age of 1526 selected participants was 52.72 ± 11.94 years old, and about 80.41% of them were male. The result of the fully adjusted model showed LDH was positively associated with in-hospital mortality in AAD patients after adjusting confounders (OR = 1.09, 95% CI 1.05 to 1.13). A nonlinear relationship was detected between LDH and in-hospital mortality in AAD patients after adjusting for potential confounders (age, gender, BMI, hypertension, diabetes, stroke, atherosclerosis, smoking, symptom, SBP, DBP, WBC, Hb, ALT, AST, ALB, Cr, type of AAD (Stanford), and management), whose point was 557. The effect sizes and the confidence intervals of the left and right sides of the inflection point were 0.90 (0.74–1.10) and 1.12 (1.06–1.19), respectively. Subgroup analysis in participants showed that the relationship between LDH and in-hospital mortality was stable, and all of the P value for the interaction in different subgroup were more than 0.05.

Conclusions

The relationship between LDH and in-hospital mortality in AAD patients is nonlinear. LDH was positively related with in-hospital mortality when LDH is more than 557.

Serum amyloid a protein as a potential biomarker in predicting acute onset and association with in-hospital death in acute aortic dissection

BACKGROUND

Acute aortic dissection (AAD) is a life-threatening disorder in vascular surgery with a high early mortality. Serum amyloid A (SAA) is a kind of acute-phase protein with a rapid diagnostic value in other diseases. However, the researches on the performance of SAA for the diagnosis of AAD is still lacking. This retrospective study aimed to evaluate the SAA levels and further explore its potential diagnostic role in AAD patients.

METHODS

SAA levels were measured by enzyme-linked immunosorbent assay (ELISA) in 63 controls and 87 AAD patients. Laboratory examinations were also performed. And relative clinical information was collected from participants included in this study.

RESULTS

SAA levels were significantly higher in AAD patients than those in healthy controls. SAA levels were independently associated with the risk of AAD. There was a positive significant correlation between SAA and C reactive protein (R = 0.442, and P = 0.001). Based on receiver-operating characteristic (ROC) analysis, the area under the curve (AUC) of SAA for the diagnosis of AAD were 0.942 with optimal cut-off points of 0.427 mg/L. For in-hospital mortality, the AUC of SAA were 0.732 with optimal cut-off points of 0.500 mg/L. According to logistic regression analysis, higher SAA levels represent a higher risk of in-hospital mortality (OR = 1.25; 95%CI: 1.07-1.47; P = 0.005).

CONCLUSION

Our findings demonstrated that SAA levels were significantly enhanced in AAD. SAA was closely correlated with inflammatory parameters and coagulation-related parameters in AAD. Furthermore, SAA could be a potential bio-marker for identifying AAD in the early diagnosis. Finally, SAA > 5.0 mg/L are independently related to AAD in-hospital mortality.

Order Indication Solicitation to Assess Clinical Laboratory Test Utilization: D-Dimer Order Patterns as an Illustrative Case

Background:

A common challenge in the development of laboratory clinical decision support (CDS) and laboratory utilization management (UM) initiatives stems from the fact that many laboratory tests have multiple potential indications, limiting the ability to develop context-specific alerts. As a potential solution, we designed a CDS alert that asks the ordering clinician to provide the indication for testing, using D-dimer as an exemplar. Using data collected over a nearly 3-year period, we sought to determine whether the indication capture was a useful feature within the CDS alert and whether it provided actionable intelligence to guide the development of an UM strategy.

Methods:

We extracted results and ordering data for D-dimer testing performed in our laboratory over a 35-month period. We analyzed order patterns by clinical indication, hospital service, and length of hospitalization.

Results:

Our final data set included 13,971 result-order combinations and indeed provided actionable intelligence regarding test utilization patterns. For example, pulmonary embolism was the most common emergency department indication (86%), while disseminated intravascular coagulation was the most common inpatient indication (56%). D-dimer positivity rates increased with the duration of hospitalization and our data suggested limited utility for ordering this test in the setting of suspected venous thromboembolic disease in admitted patients. In addition, we found that D-dimer was ordered for unexpected indications including the assessment of stroke, dissection, and extracorporeal membrane oxygenation.

Conclusions:

Indication capture within a CDS alert and correlation with result data can provide insight into order patterns which can be used to develop future CDS strategies to guide appropriate test use by clinical indication.

Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D-Dimer Concentration

Background

Clinical characteristics and treatment outcomes of acute type A aortic dissection with D‐dimer elevation have not been clarified.

Methods and Results

D‐dimer was measured preoperatively within 24 hours of symptom onset in 262 patients with acute type A aortic dissection. The median (and interquartile range) admission D‐dimer concentration in our total patient group was 26.7 (8.3–85.9) μg/mL. Median (interquartile range) D‐dimer concentrations were 5.0 (2.6–18.0) μg/mL for complete false lumen thrombosis (n=33), 60.9 (19.4–160.4) μg/mL for partial thrombosis (n=81), 26.5 (10.0–70.6) μg/mL for a patent false lumen (n=131), and 8.7 (3.2–26.9) μg/mL for ulcerlike projection (n=17) (P<0.01). With a D‐dimer concentration of ≤8.3 μg/mL representing the lower quartile, we then investigated predictors of a low D‐dimer level. Multivariate analysis showed dissection limited to the ascending aorta (P<0.01; odds ratio, 9.81) or descending aorta (P<0.01; odds ratio, 7.68), a completely thrombosed false lumen (P<0.01; odds ratio, 4.02), and absence of brain ischemia (P=0.013; odds ratio, 4.74) to be predictors of the lower D‐dimer concentration. Compared with patients with a low D‐dimer concentration (≤8.3 μg/mL, n=66), patients with a D‐dimer concentration >8.3 μg/mL (n=196) had a reduced preoperative platelet count and increased operation time and transfusion volume. In‐hospital mortality was elevated in this group (1.5% versus 11.2%; P=0.031), although 7‐year survival did not differ for hospital survivors (lower versus higher, 93.1% versus 79.1%; P=0.21).

Conclusions

D‐dimer concentrations are strongly influenced by the extent of dissection and false lumen status. Operative risks are increased in patients with a relatively high D‐dimer concentration.

Association of serum cystatin C levels with mortality in patients with acute type A aortic dissection

Increased serum cystatin C levels are related to the prognosis of cardiovascular diseases. This study aims to investigate the effect of admission serum cystatin C levels on short- and long-term mortality in patients with acute type A aortic dissection (ATAAD). From 2010 to 2014, 136 consecutive patients with ATAAD were enrolled and followed up. Clinical data and laboratory assays including were measured. During a median follow-up of 198.7 days, the short-term mortality (30-days) was 20.6%, whereas the long-term death rate was 10.2%. We identified that the expression of cystatin C and high-sensitivity C-reactive protein (hs-CRP) in the dying patients was higher than in the surviving patients (P < 0.01). Hs-CRP (HR = 1.41, 95% CI: 1.03–2.59, P = 0.037) was an independent risk factor of short-term death determined by univariate and multivariate Cox analyses. No impact of cystatin C was observed on the short-term mortality. For long-term mortality, cystatin C (HR = 1.49, 95% CI: 1.10–7.36, P = 0.013) was identified as an independent predictor at above the cut-off value ≥ 1.10 mg/L. ROC analysis showed the AUC values of cystatin C and hs-CRP were 0.772 (95% CI, 0.692–0.839) and 0.640 (95% CI, 0.574–0.739), respectively, in the prediction of long-term death. The combined AUC value of cystatin C and hs-CRP was 0.883 (95% CI, 0.826–0.935; P < 0.01). Taken together, high cystatin C levels (≥ 1.10 mg/L) on admission are independently associated with the long-term mortality in patients with ATAAD.