ADD-RS: Aortic Dissection Detection Risk Score. Stratifies patients with suspected acute aortic syndrome prior to D-dimer or imaging.
Marfan syndrome or connective tissue disease
Family history of aortic disease
Known aortic valve disease (e.g., bicuspid valve)
Known thoracic aortic aneurysm
Recent aortic manipulation / surgery
Chest, back, or abdominal pain that is: Abrupt in onset, Severe in intensity, OR Ripping/Tearing
Pulse deficit or systolic BP differential (>20 mmHg)
Focal neurological deficit (with pain)
New murmur of aortic regurgitation
Hypotension or shock state
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Patients presenting to the ED with symptoms that could represent Acute Aortic Syndrome (AAS), such as chest pain, back pain, abdominal pain, syncope, or perfusion deficits.
To safely rule out Aortic Dissection when combined with a negative D-dimer test.
Section 2
Formula & Logic
Risk Categories
The score evaluates 3 categories: High-risk predisposing conditions (e.g., Marfan), High-risk pain features (abrupt/tearing), and High-risk exam findings (pulse deficit, murmur, shock). The presence of ANY feature within a category scores 1 point for that category. Maximum score is 3.
The ADD-RS + D-dimer Pathway
01
Score = 0: Low Risk. Check D-dimer. If D-dimer < 500 ng/mL, AAS is conclusively ruled out.
02
Score = 1: Intermediate Risk. Proceed to CTA or TEE depending on stability. (Some institutions allow rule-out with D-dimer if < 500, but evidence is strongest for score 0).
03
Score = 2 or 3: High Risk. Immediate CTA or TEE. Do not delay for D-dimer.
Section 3
Pearls/Pitfalls
Missed Cases
Aortic dissection is notoriously difficult to diagnose, often mimicking MI, stroke, or renal colic. The ADD-RS was designed to have maximum sensitivity. If a patient scores 0 but you still suspect AAS strongly enough to order a CTA, rely on your clinical gestalt.
D-dimer Nuance
While highly sensitive for dissection, D-dimer can be falsely negative in cases of intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), or very delayed presentation (>24h) where thrombosis has ceased.
Section 4
Evidence Appraisal
Derivation and Validation
Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation.
Rogers AM et al. • Circulation.. 2011;123(20):2213-8. Validated the score using the IRAD (International Registry of Acute Aortic Dissection) database.
Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes.
Nazerian P et al. • Circulation.. 2018;137(3):250-258. The ADvISED prospective multicenter trial confirming the safety of the ADD-RS 0 + Negative D-Dimer rule-out pathway (Failure rate ~0.3%).
