Performance and costs of rule-out protocols for acute aortic syndromes: analysis of pooled prospective cohorts.

Summary

Using individual patient data from three prospective diagnostic cohorts (n=4,907; AAS prevalence 10.3%), guideline-aligned clinical score plus D-dimer rule-out protocols for suspected acute aortic syndromes demonstrated uniformly high sensitivity (up to 97.6%) but varied in specificity, efficiency, and cost. These results enable context-specific selection of protocols based on local policies and resource constraints.

Key Findings

• Pooled individual patient data from 3 prospective studies across 12 centers and 5 countries (n=4,907; AAS prevalence 10.3%).
• Clinical score+D-dimer protocols achieved very high sensitivity (up to 97.6%), consistent with guideline goals for rule-out.
• Specificity, efficiency, and costs varied across protocols, enabling policy- and resource-informed pathway selection.

Clinical Implications

Emergency departments can adopt highly sensitive score+D-dimer protocols while choosing versions that best balance imaging utilization and costs within local systems.

Limitations

• Abstract provides limited detail on specific D-dimer thresholds and some performance metrics
• External generalizability may vary with local imaging access and pretest probability

Future Directions

Prospective implementation studies comparing real-world outcomes, radiation exposure, and cost-effectiveness across pathways; exploration of age-adjusted or clinical probability–adjusted D-dimer thresholds.