Bedside Triage • Standardized pre-test probability
Cardiology Registry
Aortic Dissection Detection Risk Score (ADD-RS)
Registry Active
Select predisposing conditions, pain features, and exam findings to start.
Guidelines & Evidence
Verified
Last Review: 2026-07-17
When to Use
High-Acuity Triage
Adult patients presenting to the Emergency Department with symptoms suggestive of Acute Aortic Syndrome (AAS).
Symptoms include new-onset chest, back, or abdominal pain (typically described as abrupt or severe).
Evaluation of syncope or focal neurological deficits in the context of trunk pain.
Screening for perfusion deficits (pulse differential, limb ischemia, or visceral ischemia).
AAS Definition & Prevalence
Acute Aortic Syndrome (AAS) is a clinical spectrum encompassing Acute Aortic Dissection (AAD Type A & B), Intra-mural Haematoma (IMH), Penetrating Aortic Ulcer (PAU), and Aortic Rupture. Prevalence in suspected cohorts varies widely from 0.3% (DAShED study) to over 20% in high-acuity tertiary registries (ADvISED trial).
Exclusion Criteria
Primary major trauma cases (where aortic injury is secondary to blunt/penetrating force).
Incidental findings of aortic dilation/aneurysm in asymptomatic patients.
Chronic aortic conditions (>14 days from symptom onset).
How it Works
The Three Risk Categories
| Category | Specific Risk Markers (ADD-RS) | Definition |
|---|---|---|
| High-risk Conditions | Marfan, Family Hx, Valve disease, Recent manipulation | Conditions that weaken the aortic wall or involve recent instrumentation. |
| High-risk Pain | Abrupt onset, Severe intensity, Ripping/Tearing | Classic "tearing" pain is only 50% sensitive; abrupt onset is a stronger predictor. |
| High-risk Exam | Pulse deficit, BP diff (>20mmHg), Neuro deficit, AR Murmur, Shock | Physical signs of aortic branch occlusion or proximal extension (valvular/pericardial). |
Diagnostic Strategy Synthesis (Ren et al. 2024)
| Diagnostic Strategy | Sensitivity (95% CrI) | Specificity (95% CrI) |
|---|---|---|
| ADD-RS > 0 Alone | 94.6% (90.0% – 97.5%) | 34.7% (20.7% – 51.2%) |
| ADD-RS > 1 Alone | 43.4% (31.2% – 57.1%) | 89.3% (80.4% – 94.8%) |
| ADD-RS > 0 OR DD > 500 | 99.8% (98.7% – 100%) | 21.8% (12.1% – 32.6%) |
| ADD-RS > 1 OR DD > 500 | 98.3% (94.9% – 99.5%) | 51.4% (38.7% – 64.1%) |
| Canadian Guideline Strategy* | 93.1% (87.1% – 96.3%) | 67.1% (54.4% – 77.7%) |
Clinical Pearls
Insights from the ADvISED Trial (N=1850)
Failure Rate (Rule-out): For patients with ADD-RS ≤ 1 and D-dimer < 500 ng/mL, the failure rate was 0.3% (1 missed case in 312 patients).
Rule-out Efficiency: This strategy could avoid approximately 49.9% of CTA examinations in a suspected cohort.
High-Risk Prevalence: 39% of patients with an ADD-RS > 1 were adjudicated with AAS.
Case Adjudication Break-down: 125 Type A Dissections, 53 Type B, 35 IMH, 18 Ruptures, 10 PAU.
The "Anatomy" of a D-dimer Miss
| Patient Profile | Presentation | AAS Type | Clinical Clue |
|---|---|---|---|
| 72M, hx HTN/CAD | Anterior pain + syncope (2h) | Type A Dissection | Syncope/Sudden onset |
| 34M, healthy | Ant/Post pain + syncope (2h) | Type A Dissection | Age & Syncope mismatch |
| 40M, healthy | Anterior chest pain (1h) | Type A Dissection | Family Hx of AAS |
| 75M, hx HTN/DM | Ant/Post pain (24h) | IMH | Pulse deficit present |
| 78F, hx HTN/DM | Posterior pain (7 days) | Type B Dissection | Late presentation (7d) |
| 46M, Smoker | Ant/Abd pain (7 days) | Type A Dissection | Diastolic murmur present |
Key Takeaways on False Negatives
The most dangerous D-dimer misses occurred in patients with Type A dissections who presented very early (<2h) or very late (>7d). Syncope, Pulse Deficits, and New Murmurs remain "red flag" exam findings that override a negative D-dimer.
Clinical Pearls
Rely on Abruptness: "Sudden" onset of pain is often a more reliable signal than "tearing" quality.
Pulse Deficits: Check femoral and radial pulses bilaterally. A deficit is 90% specific for dissection.
Chest X-Ray Limits: A normal mediastinal width does NOT exclude AAS (up to 20% have normal CXR).
Renal Impairment: AAS can present as sudden renal failure or abdominal pain if the dissection involves renal/mesenteric arteries.
The Evidence
Primary Source: PLOS ONE 2024
Diagnostic accuracy of the aortic dissection detection risk score alone or with D-dimer for acute aortic syndromes: Systematic review and meta-analysis.
Ren S et al. • PLOS One.. 2024;19(6):e0304401. Meta-analysis of 13 studies. Included 2024 updates and a novel analysis of the Canadian clinical practice guideline.
View SourceThe ADvISED Prospective Study
Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.
Nazerian P et al. • Circulation.. 2018;137(3):250-258. Landmark trial (6 hospitals, 4 countries) validating pre-test probability integration with biomarkers.
View SourceHistorical Context (IRAD)
Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool...
Rogers AM et al. • Circulation.. 2011;123(20):2213-8. The original IRAD study that defined the 12 risk markers used in modern ACLS/AHA guidelines.
Next Steps
Management Pathway
01
Immediate BP Control: If AAS suspected, target SBP 100–120 mmHg and HR < 60 bpm (usually with Esmolol or Labetalol).
02
Definitive Imaging: ECG-gated CTA is the gold standard. TEE is preferred for unstable patients or those with severe renal failure.
03
Surgical Consultation: Urgent Cardiac Surgery (Type A) or Vascular Surgery (Type B) consult.
04
Disposition: High-risk and moderate-risk patients require ICU/Step-down admission regardless of imaging outcome if symptoms persist.
Last Comprehensive Review: 2026-07-17