Background: Acute aortic syndrome is a life-threatening condition, and its timely diagnosis poses a significant clinical challenge. Observations during the COVID-19 pandemic suggest that the routine measurement of D-dimer levels contributed to a substantial improvement in the timely diagnosis of acute aortic dissection, particularly in atypical presentations.

Objectives: To evaluate the role of D-dimer as a diagnostic biomarker for facilitating the timely diagnosis of type A acute aortic dissection.

Methods: We retrospectively analyzed two cohorts of patients: one from the pre-COVID pandemic period (2018) and the other from the COVID pandemic period (2020). We compared referral times and the relationship between these groups' D-dimer levels and diagnostic efficiency.

Results: The findings demonstrate that D-dimer testing significantly expedited surgical intervention in patients with suspected type A acute aortic dissection, which remains the definitive treatment for this condition.

Conclusions: The COVID-19 pandemic highlighted the utility of D-dimer measurement in patients with acute symptoms suggestive of aortic dissection. This readily accessible laboratory test can be implemented across various levels of healthcare facilities and plays a pivotal role in the timely diagnosis and prognosis of critical conditions.

Keywords: Acute aortic dissection, computed tomography (CT); COVID-19 pandemic; D-dimer; DeBakey classification; mortality rate; Stanford classification; surgical intervention; transesophageal echocardiography (TEE).

DOI: 10.52340/GBMN.2025.01.01.92

BACKGROUND

Acute aortic dissection is a relatively rare yet potentially fatal condition, with an estimated incidence of approximately 3.5 cases per 100,000 individuals annually.1,2 Two primary classification systems are utilized for aortic dissection: the Stanford and DeBakey systems. The DeBakey classification is based on the intimal tear's location and the dissection's extent. In contrast, the Stanford system categorizes dissections based on the involvement of the ascending aorta. Stanford type A dissections (DeBakey I and II) involve the ascending aorta and necessitate surgical intervention. In contrast, Stanford type B dissections (DeBakey III) do not include the ascending aorta and are typically managed medically.
 

The mortality rate for untreated acute aortic dissection increases by approximately 1–2% per hour after symptom onset. Advances in surgical techniques and medical management have decreased the mortality rate for type A dissection from 31% to 22%, whereas the rate for type B dissection has remained around 13%.3,4 Timely diagnosis is critical for reducing mortality; however, it is often hindered by the condition's variable presentations, which can mimic more common diseases such as acute coronary syndrome, pulmonary embolism, renal colic, or stroke. The most prevalent symptom is acute, severe pain in the chest or back, reported in 85% of patients.5
 

A subset of patients (6%) presents with atypical manifestations, such as syncope, neurological deficits, or new-onset congestive heart failure, in the absence of pain. These atypical cases are associated with higher mortality rates due to delayed diagnosis. Additionally, classic physical examination findings, such as hypertension, diastolic murmurs, or high pulse pressure, may be absent, further complicating the diagnostic process.5,7
 

The diagnosis of aortic dissection primarily relies on imaging techniques such as transthoracic or transesophageal echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). However, D-dimer, a biomarker produced during fibrin degradation, has emerged as a promising diagnostic tool. Elevated D-dimer levels are observed in various conditions, including infection, trauma, pregnancy, myocardial infarction, pulmonary embolism, and acute aortic dissection. Significantly, D-dimer levels directly correlate with outcomes in acute aortic dissection: higher levels are associated with increased mortality risk.
 

Spiral CT or CT angiography is the gold standard for imaging in hemodynamically stable patients, offering 100% sensitivity. Transesophageal echocardiography (TEE), although highly operator-dependent and subject to false positives and negatives, is often preferred for hemodynamically unstable patients.5,8,9
 

Addressing the overuse of CT imaging in emergency medicine is important, as it increases healthcare costs and extended waiting times. Incorporating D-dimer testing as a highly sensitive biomarker in patients with suspected type A aortic dissection could optimize resource use by reducing unnecessary CT scans, thereby supporting timely and accurate diagnosis.

 CONCLUSIONS 

This study underscores the potential utility of D-dimer as a valuable diagnostic tool for early detection of acute type A aortic dissection. Increased D-dimer testing during the COVID-19 pandemic was associated with a significant rise in patient referrals and reduced time to surgical intervention, ultimately lowering mortality rates. While additional research is warranted, our findings suggest that incorporating D-dimer testing into the diagnostic algorithm for acute chest pain may improve outcomes in patients with this critical condition.

 AUTHOR AFFILIATION